THE  UNIVERSITY 


OF  ILLINOIS 


LIBRARY 


■/K 


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f 


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y 


THE 


SCIENCE  AND  ART 


SURGERY. 

BEING 

A  TREATISE  SURGICAL  INJURIES,  DISEASES, 

AND  OPERATIONS. 


BY 

JOH^^  EEIC  ERICHSE]^', 

SENIOR  SURGEON  TO  UNIVERSITY  COLLEGE  HOSPITAL,  AND  HOLME  PROFESSOR  OF 
CLINICAL  SURGERY  IN  UNIVERSITY  COLLEGE,  LONDON. 

t 

A  NEW  EDITION, 

ENLARGED  AND  CAREFULLY  REVISED  BY  THE  AUTHOR. 

Illustrateb  bg  itpbarbs  of  ^eben  ^unbreb  ^ngrabings  on  Siloob. 

VOL.  1. 


PHILADELPHIA: 

HEI^RY  C.  LEA. 

1873.“ 


“  They  he  the  best  Chirurgeons  which  being  learned  incline  to  the  traditions  of 


experience^  or  being  empirics  incline  to  the  methods  of  learning.'''' 

Bacon  on  Learning. 


% 


PHILADELPHIA  S  ' 

COLLINS,  PRINTER,  705  JAYNE  STREET. 


Z  Ir  ■ 


V 

I  ■  K-t-^S6 

■ 

II  . 

■I 

i 

i 

r. 

i 

PEEFACE 

J  TO  THE  ](EW  AMERICA?^  EDITIOJf. 

i  _ 

1 

i 

The  favorable  reception  with  which  the  Science  and  Art  of 
Surgerf’  has  been  honored  bj  the  Surgical  Profession  in  the 
LTnited  States  of  America,  has  not  only  been  a  source  of  deep 
gratification  and  of  just  pride  to  me,  but  has  laid  the  foundation 
of  many  professional  friendships  that  are  amongst  the  most  agree¬ 
able  and  valued  recollections  of  my  life. 

I  have  endeavored  to  make  the  present  Edition  of  this  work 
more  deserving  than  its  predecessors  of  the  favor  that  has  been 
accorded  to  them.  In  consecpience  of  delays  that  have  unavoida¬ 
bly  occurred  in  the  publication  of  the  6th  British  Edition,  time 
has  been  afiPorded  me  to  add  to  this  one  several  paragraphs  which 
I  trust  will  be  found  to  increase  the  practical  value  of  the  work. 


London,  October,  1872. 


JOHX  ERIC  ERICHSEX. 


PREFACE 


TO  THE  SIXTH  EXGLISH  EDITIOX. 


Every  effort  has  been  made  to  render  the  “  Science  and  Art  of 
Suro’ery”  in  its  Sixth  Edition  worthy  of  that  confidence  with 

O  %j  t/ 

which  the  Profession  has  so  long  favored  it,  as  a  Guide  to  the 
Practitioner  and  a  Text-Book  for  the  Student  in  Surgery.  And 
although  little  more  than  three  years  has  passed  since  the  publica¬ 
tion  of  the  last  Edition,  it  has  been  found  necessary,  in  order  to 
enable  the  present  one  to  keep  abreast  of  the  general  advance  of 
Surgical  Science  and  Practice,  to  make  considerable  changes  in  tlie 
work,  by  which  I  trust  it  will  be  found  to  have  been  correspond¬ 
ingly  improved. 

Notwithstanding  every  desire  to  prevent  any  unnecessary  in¬ 
crease  in  the  size  of  the  Volumes,  in  has  been  found  impossible 
to  keep  them  within  the  limits  even  of  the  last  Edition,  and  a 
considerable  addition  to  the  text  has  been  rendered  unavoidable, 
although  much  matter  that  was  somewhat  obsolete  has  been 
struck  out. 

Several  chapters  have  been  recast,  and  some  almost  rewritten. 
The  alterations  and  additions  thus  made  have  not  been  confined  to 
any  one  part  of  the  Wrk,  but  have  been  very  generally  dis¬ 
tributed  through  the  x'arious  subjects  of  which  it  treats. 

Many  of  the  wood-cuts  have  been  redrawn,  and  nearly  a  hun¬ 
dred  new  illustrations  have  been  added. 

Mr.  Streatfeild  has  again  most  kindly  given  me  his  valuable 
assistance  in  bringing  up  his  Chapter  on  Ophthalmic  Surgery  to 


VI 


PREFACE. 


the  standard  of  modern  requirements,  and  has  thus  added  greatly 
to  the  value  and- utility  of  the  Work. 

To  my  friends  and  former  pupils,  Messrs.  Kiallmark  and  Beck, 
I  am  indebted  for  much  valuable  assistance  in  the  preparation  of 
this  Edition :  to  Mr  Kiallmark  for  the  aid  he  has  o-iveii  me  in  the 

o 

earlier  ftarts  of  the  first  volume,  and  to  Mr.  Beck  for  that  which 
he  has  rendered  me  throughout  the  Work. 

To  Dr.  A.  Henrv  I  am  again  indebted,  as  I  have  been  in  several 
former  Editions,  for  materially  lightening  the  literary  labor  that 
would  otherwise  have  devolved  on  me  in  carrying  this  one  through 
the  press,  and  for  several  most  useful  suggestions  in  connection 
with  its  arrangement. 

I  can  but  hope  that  the  present  Edition  of  the  “  Science  and  Art 
of  Surgery  ”  will  be  found  to  deserve  the  same  favorable  reception 
that  the  preceding  ones  have  met  with  from  Surgeons  and  Pupils 
in  this  country,  the  Colonies,  the  United  States  of  America,  and 
many  parts  of  the  Continent  of  Europe. 

JOHX  EKIC  EEICHSEX. 

6,  Cavendish  Place,  London,  W., 

October.,  1872. 


NOTE. 


The  Science  and  Art  of  Surgery  constitutes  that  great  Depart¬ 
ment  of  Medicine  in  its  widest  acceptation,  which  comprises  the 
consideration  of — 

1.  Injuries — from  whatever  cause  arising — and  whatever  part 

affecting — to  which  the  human  frame  is  liable — their  IN'ature 

— mode  of  Repair  and  Treatment. 

2.  Malformations  and  Deformities — Congenital  and  Acquired. 

3.  External  Diseases — and  all  those  Diseases  that  specially  or 

primarily  affect  the  Organs  of  Sense,  of  Locomotion,  and  of 

Reproduction  in  both  Sexes. 

4.  Diseases  that  are  the  direct  consequences  of  Injury. 

5.  Diseases  that  require  Manual,  Mechanical,  or  Operative  means 

,  for  their  cure  and  relief. 

6.  Operations  of  whatever  kind  that  are  required  for  the  Cure, 

Removal,  or  Relief  of  any  of  the  above  Conditions  or  Diseases. 

For  the  consideration  of  these  various  subjects,  this  Work  is  di¬ 
vided  into  three  parts: 

The  First — under  the  head  of  General  Principles — contains 
general  observations  on  Operative  Surgery,  more  especially  on  Am¬ 
putations,  and  a  condensed  view  of  the  Hature  and  Treatment  of 
Inhammation  from  a  Surgical  aspect. 

The  Second  Division  comprises  the  considelation  of  Surgical 
Injuries. 

The  Third  contains  that  of  Surgical  Diseases. 

In  considering  both  Injuries  and  Diseases^  the  following  arrange¬ 
ment  has  been  adopted: — 

1.  Those  common  to  all  Parts  of  the  Body.  As  in  Injuries — 

Wounds.  In  Diseases — Erysipelas — Tumors. 

2.  Those  affecting  Special  Tissues.  As  in  Injuries — Fractures  of 

Bones  and  Wounds  of  Bloodvessels.  In  Diseases — Caries, 

R’ecrosis,  and  Aneurism. 

3.  Those  affecting  respectively  different  Regions  of  the  Body — 

as  the  Head,  Chest,  or  Abdomen. 


Vlll 


NOTE. 


In  treating  of  tliese  various  subjects,  the  descriptions  that  are 
given  of  tlie  Symptoms,  Causes,  Diagnosis,  and  Treatment,  are  as 
full  as  the  importance  of  each  demands,  and  the  present  state  of 
knowledge  permits.  But  as  a  full  examination  of  the  important 
researches  made  in  recent  years  in  Pathology  would  not  be  possible 
in  a  work  intended  principally  to  teach  the  Practice  of  Surgery, 
this  subject  is  introduced  to  a  sufficient  extent  only  to  place  before 
the  student  a  summary  of  the  most  approved  observations,  espe¬ 
cially  those  which  are  likely  to  be  of  clinical  or  practical  value. 
Diagnosis  receives  special  attention;  and,  as  accuracy  in  this  is  an 
all-important  requisite  for  success  in  Treatment,  the  conditions  with 
which  each  injury  or  disease  may  be  confounded  are  carefully  de¬ 
scribed,  and  the  means  of  distinguishing  one  from  another  pointed 
out. 

Throughout  the 'Work,  the  object  is  to  place  before  the  prac¬ 
titioner  and  student  the  Science  and  Art  of  Surgery,  not  as  consist¬ 
ing  merely  in  the  observation  of  such  Diseases,  Injuries,  and  Mal¬ 
formations  as  belong  to  the  classes  mentioned  above,  or  in  the  dex¬ 
terous  application  of  manual  or  operative  means  for  their  relief ; 
but  as  demanding  an  exercise  of  general  Medical  knowledge,  and 
a  thorough  acquaintance  with  all  those  conditions,  whether  intrinsic 
to  the  patient  or  surrounding  him,  that  favor  or  prevent  his  restora¬ 
tion  to  health.  '  . 

J.  E.  E. 


CONTEXTS  OF  THE  FIRST  VOLUME. 


DIVISIOX  FIRST. 

FIRST  PRINCIPLES. 

Chapter  I. — General  Considerations  on  Operations. 

PAGE 

Objects  of  Surgical  Operations — Nature  of  Knowledge  required — Condi¬ 
tions  Influencing  Success  of  Operations — Causes  of  Danger  and  Death — 
Preparations  for  Operation. — Anaesthetics — Chloroform — Its  A\dministra- 
tion — Secondaiy  Effects — Death  from  Chloroform — Ether — Nitrous  OA^ide — 
Bichloride  of  Methylene — Treatment  of  Eflect  of  Over-dose  of  Anresthetics 
— Local  Anaesthesia. — OpeRaATIon — Incisions — Sutures — Dressing — A^fter- 
Treatment . 17-40 

Chapter  II. — Amput.attons  and  DiSaARTicuLaAtions. 

Amputations — Prevention  of  Hemorrhage — Modes  of  Amputating — Flap 
AA.mputation — Instruments — Double  Flaps — Rectangular  Flaps — Long  Flap 
— Sawing  the  Bone — A^rrest  of  Hemorrhage — Dressings — A^ccidents  in  Heal¬ 
ing  of  Stump — Simultaneous  A^mputations — Structure  of  a  Stump — Artiflcial 
Limbs — Morbid  Condition  of  Stumps — A\neurismal  Enlargement  of  Arteries 
— Painful  and  Spasmodic  Stumps — Strumous,  Malignant,  and  Fatty  Degene¬ 
ration  of  Stumps. — MorTaALITT  aAFTER  aImputation — A\.ge — General  Health 
— Hygienic  Conditions — Seat  of  A\mputation — Part  of  Bone — Injur}'  or  Dis¬ 
ease — Nature  of  Disease — Time  of  Performance — Primary  and  Secondary 
Amputations — Statistics . .  40-o9 

Ch.APTER  III. — SpECIaAL  AmPUTaATIONS. 

Upper  Limb — Fingers — Metacarpo-Phalangeal  Joints — Thumb^Metacarpal 
Bones — AV rist — Forearm — A\rm — Shoulder- Joint — General  Results  of  A\mpu- 
tations  of  the  Upper  Limb. — Lower  Limb — Toes — Metatarsal  Bones — 
Chopart’s  Operation — Syme's  Disarticulation  of  the  Ankle-Joint — PirogofTs 
Operation — Subastragaloid  Almputation — Results  of  Almputations  of  Foot — 
Amputations  of  the  Leg — Flap  A^mputation — Results — Almputation  through 
the  Knee-Joint — Yermale’s  Operation — Amputation  of  Upper  and  Middle 
Thirds  of  the  Thigh — Through  the  Trochanters — Results  of  A\mputation  of 
Thigh — A^mputation  at  Hip- Joint — Results . 59-92 


X 


CONTEXTS. 


Chapter  IY _ Inflammation. 

PAGE 

Congestion — Symptoms — Effects — Causes — Treatment. — Determination — 
Symptoms — Effects — Causes — Treatment. — Acute  Inflammation  —  Phe¬ 
nomena— Condition  of  Vessels — State  of  Blood — Symptoms — Local  Signs — 
Constitutional  Symptoms — Inflammatory  Fever — Sthenic,  Asthenic,  and 
Irritative — Terminations,  Extension,  and  Effects  of  Acute  Inflammation — 
Varieties — Causes — Treatment. — Chronic  Inflammation  —  Pathology — 
Phenomena — Constitutional  Symptoms — Causes — Treatment  .  .  92-122 

Chapter  Y. — Suppuration  and  Abscess. 

Suppuration — Characters  of  Pus — Diagnosis — Pyogenesis — Relation  of  Supy 
puration  to  other  Changes  in  the  Tissues — Circumstances  influencing  the 
Tendency  to  Suppuration — Duration — Symptoms — Forms  in  which  Suppu¬ 
ration  occurs. — Abscess — Definition — Varieties — Acute  or  Phlegmonous — 
Chronic — Cold,  Lymphatic  or  Congestive — Diffuse — Puerperal — Metastatic 
— Tympanitic  or  Emphysematous — Situation  and  Size — Effects — Diagnosis 
— Prognosis — Treatment — Of  Acute  Abscess — Of  Chronic  Abscess — Tumors 
— Tapping  —  Potassa  Fusa  —  Drainage-Tubes  —  Antiseptic  Treatment — 
Hemorrhage  into  Cavity  of  Abscess. — Sinus  and  Fistula — Causes  and 
Structure — Treatment . 123-141 


Chapter  YI. — Ulceration. 

Ulceration  defined — Causes — Situation — Stages — Repair  of  Ulcers — Granu¬ 
lation — Cicatrization — Treatment — Transplantation  of  Cuticle. — Forms  of 
U LCER — Healthy  or  Purulent — W eak — Indolent  —  Irritable  —  Ipflamed — 
Sloughing — Varicose — Hemorrhagic — On  Mucous  Membranes  .  141-152 


Chapter  YII. — The  Process  of  Repair. 

3Iodes  of  Union  of  Wounds — First  Intention — Scabbing  or  Incrustation — 
Adhesive  Inflammation  —  Vascularization  of  Lymph  —  Degeneration  of 
Lymph — Granulation — Union  of  Granulating  Surfaces  —  Circumstances 
aflecting  the  Healing  Process . 152-158 


DIYISIO^T 

SURGICAL  INJURIES. 

Chapter  YIII. — Effects  of  Injury. 

Shock — Symptoms — Causes — Pathology — Treatment. — Traumatic  Fever. — 
Traumatic  Delirium. — Remote  Effects  of  Injury — Constitutional — 
Local  . 159-104 


COXTEXTS. 


XI 


Chapter  IX. — Injuries  of  Soft  Parts. 

PAGE 

CoNTU siONS — Causes  —  Degrees  —  Diagnosis  —  T reatment  —  Strangulation  of 
Parts. — W OUNDS — How  classified. — Incised  Wounds — Symptoms — Man¬ 
agement — Local  Treatment — Antiseptic  Treatment  of  Wounds — Inflamma¬ 
tion  of  Incised  Wounds. — Contused  and  Lacerated  Wounds — Slousrh- 

o 

ing — Traumatic  Gangrene  —  Treatment  —  Indications  for  Amputation. — 
Brushburn — Treatment. — Punctured  Wounds — Treatment  .  164-187 

Chapter  X. — Gunshot  Wounds. 

Gunshot  Wounds  in  General — Circumstances  affecting  Character — Xature 
and  Force  of  Projectile — Direction — Apertures  of  Entry  and  Exit — Symp¬ 
toms — Treatment — Hemorrhage — Extraction  of  Foreign  Bodies — Treatment 
of  Wound — Cases  requiring  Amputation. — Gunshot  Wounds  of  Special 
Bones  and  Joints .  187-205 

Chapter  XI. — Poisoned  Wounds. 

Stings. — Snake-Bites  —  Effects  of  Snake-Poison — Treatment. — Bites  of 
Rabid  Animals  —  Hydrophobia  —  Symptoms  —  Prognosis  —  Pathology  — 
Treatment. — Wounds  with  Inoculation  of  Decomposing  Animal  Mat¬ 
ter — Causes — Symptoms — Treatment .  206-215 

Chapter  XII. — Effects  of  Heat  and  Cold. 

Burns  and  Scalds — Local  Effects — Degrees — Constitutional  Effects — Progno¬ 
sis — Mode  of  Death  from  Burns — Treatment — Prevention  and  Removal  of 
Contraction — W arty  Cicatrices — Amputation. — Frost-Bite — Local  Influ¬ 
ence  of  Cold — Constitutional  Effects — Treatment  ....  216-227 

Chapter  XIII. — Injuries  of  Bloodvessels. 

Injuries  of  Veins — Venous  Hemorrhage — Diffuse  Phlebitis. — Injuries  of 
Arteries — Contusion — Rupture  and  Laceration — Wounds,  Xon-Penetra- 
ting  and  Penetrating. — Hemorrhage  from  Wounded  Vessels — Local 
Sis:ns — Distinctive  Characters  of  Arterial  and  Venous — Extravasation — 
Constitutional  Effects — General  Treatment — Transfusion  of  Blood  .  227-232 

Chapter  XIV. — Arrest  of  Arterial  Hemorrhage. 

Natural  Arrest  of  Hemorrhage — History  of  Investigations — Temporary 
Means — Changes  in  the  Blood  and  in  the  Heart’s  Action — Retraction  and 
Contraction  of  the  Artery — Formation  of  Coagulum — Permanent  Closure — 
Adhesion — Contraction — Arrest  of  Hemorrhage  from  Punctured  Arteries. — 
Surgical  Treatment — Temporary  Means — Compression  of  Artery — Tour¬ 
niquet —  Permanent  Means — Cold — Styptics — Cauterization — Direct  Pres¬ 
sure  —  Forcible  Flexion — Torsion  —  Ligature — History — Principles — Appli¬ 
cation  —  Modifications  —  Effects  —  Acupressure  —  Collateral  Circulation. — 
Accidents  after  Arterial  Occlusion  by  Surgical  Means — Secondary 
Hemorrhage — Gangrene  . .  232-269 


XU 


CONTENTS. 


Chapter  XT. — Traumatic  Aneurism  and  Arterio-Tenous  Wounds. 

PAGE 

Traumatic  Aneurism  —  Diffused  —  Circumscribed.  —  Arterio-Venous 
Wounds — Aneurismal  Tarix — Varicose  Aneurism  ....  270-27G 

Chapter  XVI. — AVounds  of  Special  Bloodvessels. 

Vessels  of  Head  and  Xeck— Carotid  Artery — Aneurismal  A^arix  of  Inter¬ 
nal  Jugular  A^ein — Traumatic  Aneurism  of  Temporal  Artery — Deep  Arte¬ 
ries  of  Face. — Vessels  of  Upper  Limb — Subclavian  Artery — AYound — 
Aneurismal  A'arix  —  Axillary  —  Open  AA'ounds  —  Traumatic  Aneurism — 
Bracliial  Artery — AA'ounds — Traumatic  Aneurism — A^aricose  Aneurism — 
Aneurismal  A^arix — Arteries  of  the  Forearm  and  Palm — Traumatic  Aneurism 
of  Kadial  and  Ulnar  Arteries — AYounds  of  Palmar  Arteries — Circumscribed 
Traumatic  Aneurism  in  the  Palm.— Vessels  of  Lower  Limb — Femoral 
Artery  and  its  Branches — Diffused  Traumatic  Aneurism — Arteries  of  the 
Leg  and  Foot — AYounds  and  Traumatic  Aneurisms — Traumatic  Aneurism 
of  Gluteal  Artery .  276-285 

Chapter  XA^II. — Entrance  of  Air  into  A^eins. 

Air  in  Veins— Results  of  Experiments  on  Animals — Spontaneous  Entry  in 
Alan — Local  Phenomena — Constitutional  Effects — Cause — Preventive  Treat¬ 
ment — Curative  Treatment — Indications  to  be  followed  .  .  .  286-292 


Chapter  XA'III. — Injuries  of  Xerves,  AIuscles,  and  Tendons. 

Injuries  of  Nerves — Contusion — Puncture — Division — Repair. — Injuries 
OF  AIuscles  and  Tendons— Sprains  or  Strains — Rupture  and  Division — 
Union — Treatment .  292-295 

Chapter  XIX. — Injuries  of  Bones  and  Joints. 

Injuries  of  Bones — Bruising— Bending. — Injuries  of  Joints— Contu¬ 
sions — Sprains — Treatment — AA’^ounds  of  Joints — Symptoms  and  Effects — 
Traumatic  Arthritis— Treatment. — AA^ounds  of  Individual  Joints— Hip 
and  Shoulder — Knee — Ankle — Elbow — AYrist  .....  296-301 

Chapter  XX. — Fractures. 

Fracture — Causes — Y"arieties — Nature — Direction — Signs — Union — In  Sim¬ 
ple  Fracture — In'  Compound  Fracture. — Treatment  of  Simple  Frac¬ 
ture — Reduction — Prevention  of  Return  of  Displacement — Bandages — 
Splints — Starched  Bandage — Plaster  of  Paris  Bandage. — Accidents  during 
Treatment — Spasm — Extravasation  of  Blood — (Edema  and  Gangrene — 
Pulmonary  and  Cerebral  Congestion. — Complicated  Fractures — Treat¬ 
ment. — Compound  Fracture — Removal  of  the  Limb — Treatment  of  Com¬ 
pound  Fracture — Bending,  Rebreaking,  and  Resetting  Bones — Delayed 
Union — Ununited  Fracture  and  False  Joint .  301-339 


CONTENTS. 


Xlll 


Chapter  XXI. — Special  Fractures. 

PAGE 

Bones  op  the  Face — Nasal  Bones — Ma^ar  and  Upper  Jaw  Bones — Lower 
Jaw — Hyoid  Bone. — Bones  of  the  Chest — Ribs  and  Costal  Cartilages — 
Sternum. — Upper  Extremity — Clavicle— Scapula— Humerns— Forearm — 
Metacarpus  and  Fingers. — Lower  Extremity — Pelvis — Sacrum — Coccyx 
— Femur — Patella — Tibia  and  Fibula — Foot .  340-390 

Chapter  XXII. — Dislocations. 

Dislocation  defined — Causes — Signs — Effects — Treatment — Mechanical  Con¬ 
trivances — Extension — Dislocation  of  old  Standing — Treatment — Dangers 
of  Attempts  at  Reduction — Compound  Dislocation — Treatment — Complica¬ 
tions — Spontaneous  Dislocation — Congenital  Dislocation  .  .  .  390-401 

Chapter  XXIII. — Special  Dislocations. 

Lower  Jaw — Causes — Bilateral — Unilateral — Reduction — Congenital  Dislo¬ 
cation. — Clavicle — Sternal  End — Acromial  End — Simultaneous  of  both 
Ends. —  Scapula. — Humerus  — Varieties  —  Subcoracoid  —  Subclavicular — 
Subspinous  —  Subglenoid— Partial — Causes  —  Relative  Frequency — Diagno¬ 
sis — Treatment — Compound  —  Congenital  —  Unreduced — Accidents  in  At¬ 
tempted  Reduction. — Elbow  Joint — Both  Bones — Ulna — Radius — Com¬ 
plications — Treatment — Compound — Old  Unreduced  Dislocations. — Wrist 
— Backwards  —  Forwards  —  Diagnosis  —  Compound — Congenital.— Single 
Carpal  Bones  —  Os  Magnum  —  Pisiform  —  Semilunar.  —  Metacarpal 
Bones.  —  Metacarpo-Phalangeal  Joints  —  Thumb. — Phalanges  op 
Fingers. — Pelvis — Pubic  Symphysis— Sacro-Iliac  Articulation — Coccyx. 

— Hip — Cooper’s  Classification — Importance  of  Ilio-Femoral  Ligament — 
Bigelow’s  Classification — Varieties — Modes  of  Reduction — Ilio-Sciatic — On 
Thyroid  Foramen — On  Pubic  Bone — Other  Forms — Reduction  of  Old  Dis¬ 
locations — Complication  with  Fracture — Simultaneous. — Patella. — Knee 
— Varieties — Subluxation  —  Complications  —  Compound  Dislocation — Head 
of  Fibula. — Ankle  — Varieties'  —  Compound. —  Astragalus  —  Varieties  — 
Treatment — Compound. — Tarsal  Bones — Calcaneum  and  Scaphoid — Cal- 
caneum — Scaphoid  and  Cuboid  — Great  Cuneiform. — Metatarsal  Bones 

402-445 


Chapter  XXIV. — Injuries  of  the  Head. 

Cerebral  Complications  of  Injuries  op  the  Head — Concussion — Com¬ 
pression — Cerebral  Irritation — Contusion  of  the  Brain — Effects  of  Cerebral 
Injury  on  Mental  Powers — Traumatic  Encephalitis — Intracranial  Suppura¬ 
tion — Treatment  of  Cerebral  Injuries  and  their  Effects. — Injuries  of  the 
Scalp  —  Contusions —  Cephalhaematoma — Wounds. —  Fractures  of  the 
Skull — Contusion  of  Cranial  Bones — Causes  and  Varieties  of  Fracture — 
Contre-coup — Simple  Fracture — Fracture  of  the  Base  of  the  Skull — Signs 
— Hemorrhage — Discharge  of  Watery  Fluid — Depressed  Fracture — Varieties 
— Symptoms — Wounds  of  the  Dura  Mater — Treatment  of  Depressed  Frac¬ 
ture — Injuries  op  the  Contents  of  the  Cranium — Wounds  of  the  Brain 
and  its  Membranes — Causes — S3unptoms  and  Effects — Diabetes — Injuries  of 
Cranial  Nerves — Fungus  or  Hernia  Cerebri — Extravasation  of  Blood  within 
the  Skull — Symptoms — Diagnosis — Operation  of  Trephining.  .  .  446-484 


XIV 


CONTEXTS. 


Chapter  XXY. — Injuries  of  the  Spine. 

PAGE 

Concussion  of  the  Spinal  Cord — Definition. — Concussion  fron  Direct 
Violence — Primary  Symptoms — Secondary  Symptoms — Causes  of  Death — 
Injuries  of  Vertebral  Column — Effects  of  Slight  Blows. — Concussion  from 
Indirect  Violence — Secondary  Effects — Pathological  Conditions — Diag¬ 
nosis — Prognosis  of  Spinal  Concussion — Treatment. — Wounds  of  the 
Spinal  Cord — Symptoms — In  Lumbar  and  Lower  Dorsal  Region — In 
Middle  Dorsal  Region — In  Lower  Cervical  Region — Above  Phrenic  Nerve. 

— Mechanical  Injuries  of  the  Vertebral  Column. — Sprains — Symp¬ 
toms — Prognosis. — Fracture — Signs  and  Symptom.s — Treatment. — Dis¬ 
locations — Of  Atlas  from  Occipital  Bone — Of  Axis  from  Atlas — Of  Lower 
Cervical  Vertebrse — Of  Transverse  Processes  of  Cervical  Vertebrae — Of  Dor¬ 
sal  Vertebrae .  484-508 

Chapter  XXVI. — Injuries  of  the  Face  and  Adjacent  Parts. 

Face — Cuts  of  Cheeks  and  Forehead — Lips — Parotid  Duct — Salivary  Fistula 
— Foreign  Bodies  in  Nose. — EARS--Wounds — Foreign  Bodies. — Orbit — 
Danger  of  Injuries  of. — Eye— Contusion — Contusion  with  Rupture — 
Wounds,  Penetrating  and  Non-Penetrating — Indirect  Injury  of  the  Eye. — 
Mouth. — Tongue. — Palate  and  Pharynx .  508-517 

Chapter  XXVII. — Injuries  of  the  Throat:  and  Asphyxia. 

Injuries  of  the  Larynx  and  Trachea — Dislocation  and  Fracture  of  Larynx  [ 
— Wounds  of  Throat — Not  extending  into  Air-passage — Implicating  Air- 
passage — Treatment — Aerial  Fistula — Foreign  Bodies  in  Air-passage — Symp¬ 
toms — Prognosis — Treatment — Scald  of  Mouth,  Pharynx,  and  Glottis — 
Treatment. — Asphyxia  or  Apncea — Causes — From  Drowning — Artificial 
Respiration — Inflation  with  Oxygen  Gas — Secondary  Asphyxia-^From  Nox¬ 
ious  Gases — From  Hanging. — Pharynx  and  (Esophagus — Wounds — 
Foreign  Bodies — Pharyngotomy  and  (Esophagotomy  .  .  .  517-534 

Chapter  XXVIII. — Injuries  of  the  Chest. 

Wounds  of  the  Chest. — Injuries  of  the  Luno-^ Contusion — Rupture — 

W  ound  —  Symptoms  —  Complications  —  Hemorrhage  —  Hsemothorax — Em¬ 
physema  and  Pneumothorax — Pneumonia — Pleurisy  and  Empyema — Col¬ 
lapse  of  Lung — Prognosis — Treatment — Hernia  of  Lung,  or  Pneumocele.-r 
Wounds  OF  the  Heart  and  Large  Vessels — Wounds  of  the  Pericardium 
— Wounds  of  the  Heart — Rupture  of  the  Heart  from  External  Violence — 
Wounds  of  the  Aorta  and  Vena  Cava .  534-546 

Chapter  XXIX. — Injuries  of  the  Abdomen  and  Pelvis. 

Injuries  of  the  Abdomen  and  Abdominal  Viscera — Contusion  of  the 
Abdominal  Walls — Buffer-Accidents — Rupture  of  Abdominal  Viscera — Em¬ 
physema  of  Abdominal  Wall — Wounds  of  Diaphragm — Wounds  of  Ab¬ 
dominal  Wall — Non-penetrating — Penetrating — Without  Wound  or  Protru¬ 
sion  of  Viscera — With  Wound  or  Protrusion — Wounds  of  Intestine — 


CONTEXTS. 


XV 


PAGE 

Treatment— Traumatic  Peritonitis— Treatment.— Injuries  of  the  Pelvic 
Viscera- Rupture  of  Bladder — Foreign  Bodies  in  Bladder — Rupture  of 
Ureter — Wounds  of  Organs  of  Generation — Wound  of  Urethra — Laceration 
of  L^retlira — Foreign  Bodies  in  Vagina  or  Rectum — Laceration  of  the  Peri- 
ncTum . .  547-564 


DIVISIOX  THIRD. 

SURGICAL  DISEASES. 

Chapter  XXX. — Mortification,  or  Gangrene. 

Gangrene  Defined — Local  Signs — Constitutional  Symptoms — Causes — Gan¬ 
grene  from  Arrest  of  Supply  of  Arterial  Blood — Ligature  or  Wound  of 
Artery — Thrombosis — Embolon — Senile  Gangrene — Gangrene  from  Obstruc¬ 
tion  of  Circulation  through  a  Part — Venous  Obstruction — Strangulation — 
Inflammation — Arrest  of  Gangrene — Lines  of  Demarcation  and  Separation 
— Diagnosis  — Prognosis  —  Treatment  —  Constitutional  —  Local  —  of  Senile 
Gangrene — Amputation .  565-570 

Chapter  XXXI. — Gangrenous  Diseases. 

Bed-Sores — Treatment. — Sloughing  Phagedena — Local  Signs— Constitu¬ 
tional  Symptoms — Causes— Treatment. — Gangrenous  Stomatitis  or  Can- 
crumOris — Signs — Treatment. — Boils— Causes — Treatment. — Carbuncle 
— Signs — Diagnosis — Prognosis — Treatment .  579-588 


Chapter  XXXII. — Erysipelas. 

Erysipelas— Characters — Erysipelatous  Fever — Causes — Intrinsic — Hygienic 
Influences — States  of  Blood — Extrinsic — Season — Contagion. — External 
Erysipelas — Cutaneous — Cellulo-Cutaneous—  Cellular  —  Diagnosis — Prog¬ 
nosis — Treatment— Of  Cutaneous  Erysipelas — Of  Cellulo-Cutaneous  Ery¬ 
sipelas — Of  Cellular  Erysipelas — Special  Forms — In  Xewly  born  Infants — 
Orbit — Head —  Scrotum  —  Pudenda — Whitlow. — Internal  Erysipelas — 
Erysipelas  of  Mucous  Membranes — Fauces — Larynx — Of  Serous  Membranes 
— Arachnoid — Peritoneum  .  .  .  • .  588-606 

Chapter  XXXIII. — Py^^mia. 

Pyemia  Defined — Causes — Phenomena— Formation  of  Purulent  Deposits — 
Diagnosis — From  Inflammatory  and  Typhoid  Fevers — From  Ague — From 
Rheumatism — Prognosis — Pathology — Leucocytosis — Trombosis  and  Em¬ 
bolism — Formation  and  Changes  of  a  Thrombus — Embolon — Ichorrhsemia 
or  Septicgemia — Post-mortem  Appearances — Blood — Heart — Lungs — Liver 
— Spleen — Kidneys — Intestines — Joints — General  Character  of  Anatomical 
Lesions — Treatment .  606-621 


XVI 


CONTENTS. 


Chapter  XXXIY. — Tumors. 

PAGE 

Deposition. — Classification — Non-malignant,  Benign,  or  Innocent  Tu¬ 
mors — Malignant  Tumors — Signs  of  Malignancy — Semi-malignant  Tumors 
— Clinical  Classification — Anatomical  Classification, — I.  Cystic  Tumors — 
Classification  according  to  Contents — Dermoid  Cysts — Serous  Cysts— Colloid 
Cysts — Classification  according  to  Development — Encysted  Tumors  from 
Simple  Distension  of  Walls  of  Duct  or  Cyst — Of  Sebaceous  Glands — Pro¬ 
gress — Diagnosis — Treatment — Of  other  Excretory  Organs — Distension  of 
Cavities  without  Excretory  Ducts — Bursae — Cystic  Tumors  of  Ovary — 
Cysts  as  New  Formations — Simple  or  Serous  Cysts — Compound,  Prolifer¬ 
ous,  or  Multilocular  Cysts — Sanguineous  Cyst  or  Haematoma — Pilo-C5^stic 
Tumors  or  Dermoid  Cysts — Cholesteatoma. — II.  Tumors  Produced  ry 
Local  Hyperplasia  of  Complex  Structures — Tumors  connected  with 
Integumental  Structures — Corns — Warts — Condylomata  and  Mucous  Tu¬ 
bercles — Cheloid — Treatment — Polypi — Hypertrophy  of  Glandular  Struc¬ 
tures. — III.  Tumors  of  the  Connective  Tissue  Type — Classification 
— Derived  directly  from  Connective  Tissue — Fatty  and  Adipose  Tumors — 
Lipoma — Fibroid  Tumors — Malignant — Fibroid — Sarcomata — Areolar  Tu¬ 
mors — Fibro-cellular  Tumors — Glioma  and  Myxoma — Recurring  Fibroid 
Tumors — Fibro-Plastic  and  Myeloid  Tumors — Granulation  Tumors — Tu¬ 
mors  formed  on  the  Type  of  Cartilage— Enchondroma — Microscopical 
Characters— Locality — Treatment — Tumors  formed  on  the  Type  of  Bone. — 

IV.  Tumors  of  the  Epithelial  Type— Cancer — Scirrhus  and  Encepha- 
loid — Microscopic  Structure — Progress — Scirrhus — Structure — Encephaloid 
— Structure — Other  Varieties  of  Cancer — Colloid,  Gelatinous,  or  Alveolar — 
Melanosis  or  Black — Causes — Diagnosis  of  Forms  of  Cancer — Causes — 
Mental  Emotions — Constitutional  or  Local  Origin— Secondary  Deposits — 
Treatment — Constitutional  Means  Useless — Local  Means — Palliative — Cura¬ 
tive — Caustics — Acids — Alkalies — Chlorides — Arsenic — Sulphate  of  Zinc — 
Compression— Excision — Question  of  Operating — Cases  not  Admitting 
Operation — Doubtful  Cases — Cases  Proper  for  Operation. — EpiIthelioma — 
Situation  and  Progress  —Structure — Diagnosis— Prognosis— Treatment — 
Excision — Ligature— Ecraseur — Caustics. — Excision  of  Tumors  .  621-674 

Chapter  XXXV _ Scrofula  and  Tubercle. 

Scrofula — Definition — Scrofulous  Diathesis — Scrofulous  Temperament — Stru¬ 
mous  Inflammation — Of  Skin — Mucous  Membranes — Bones  and  Joints — 
Glandular  Organs. — Tubercle — Structure — Progress. — Causes  of  Scro¬ 
fula  AND  Tubercle — Hereditary  Nature — Malnutrition — Debility  from 
Disease. — Treatment — Preventive — Curative — Local  Treatment. — Opera¬ 
tions  IN  Scrofulous  and  Tuberculous  Cases  ....  674-683 

Chapter  XXXVI. — Venereal  Disease. 

Definition  and  Classification. — I.  Local  Contagious  Ulcer  or  Chan¬ 
cre — Characters — Specific  Nature — Origin  and  Progress — Varieties — Simple 
or  Soft — PhagedfBiiic — Sloughing  Chancre,  or  Gangrenous  Phagedaena — 
Situation  of  Chancre — Diagnosis — Local  Treatment  of  Chancre — Of  Phage- 
daenic  Chancre — Of  Sloughing  Chancre — Constitutional  Treatment. — Con¬ 
secutive  Symptoms  of  the  Local  Contagious  Ulcer — Contracted 


CONTENTS. 


XVll 


PAGE 

Cicatrices — Bubo — Primary  Bubo — Creeping  Bubo — Treatment — Venereal 
"Warts. — II.  Syphilis,  or  Constitutional  Venereal  Disease — Cha¬ 
racters — Origin — Transmisibility — Progress — Indurated  or  Hunterian  Chan¬ 
cre — Seat  and  Number — Induration — Indolent  Enlargement  of  Lymphatic 
Glands — Treatment— Use  of  Mercury. — Secondary  or  Constitutional 
Manifestations  of  Syphilis — Phenomena — Circumstances  Influencing 
Progress — Treatment— Mercury, — Local  Secondary  Affections— Syphi¬ 
litic  Skin  Diseases — Warts,  Excrescences,  and  Vegetations— Syphilis  of 
Mucous  Membranes— Syphilitic  Iritis — Periosteum  and  Bones — Nodes — 
S3’'philitic  Necrosis  and  Caries — Sj-philitic  Disease  of  Testicle — S3'philitic 
Ovaritis — S3^philis  of  Muscles  and  Tendons. — Infantile  Syphilis — 
Nature — Mode  of  Communication — S3unptoms  —  Influence  on  Teeth  — 
Treatment  ............  C83-725 

Chapter  XXXVII _ Surgical  Diseases  of  the  Skin  and  its 

Appendages. 

Diseases  of  the  Appendages  of  the  Skin — Warts— Corns — Diseases  of  the 
Nails -Onychia — Ingrowing  of  the  Nails — Hypertropln^  of  Toe-Nail. — 
Malignant  Tumors  and  Ulcers  of  the  Skin — Cheloid  and  Fibro- 
Vascular  Tumors — Lupus — Varieties — Lupus  Mon  exedens — Lupus  Exedens 
— Microscopic  Structure— Diagnosis — Treatment — Lupoid  or  Eodent  Ulcer 
— Symptoms — Patholog3" — Treatment— Cancer  of  the  Skin — Scirrhous  Wart 
— Infiltrated  Cancer — Cancerous  Ulcer — Treatment  ....  725-737 

Chapter  XXXVIII. — Diseases  of  the  Nervous  System. 

Neuritis  —  Symptoms  — Treatment. —  Neuralgia  —  S3miptoms  —  Causes — 
Diagnosis  —  Treatment.  —  Neuroma  —  Structure  —  Traumatic  Neuroma  — 
Treatment. — Traumatic  Paralysis — From  Injuiy  of  Brain — From  Injuiy 
of  Spinal  Cord — From  Pressure  on  Nerves — Diagnosis. — Tetanus — Causes 
— Period  of  Occurrence — Forms — Symptoms — State  of  Nerves  at  Seat  of 
Injury — Pathology — Treatment .  737-754 

Chapter  XXXIX. — Diseases  of  the  Lymphatics  and  tiieip*. 

Glands. 

Inflammation  of  the  Lymphatics,  Lymphatitis,  or  Angeioleucitis — 
Symptoms — Kesults— Diagnosis — Causes — Treatment. — Inflammation  of 
Lymphatic  Glands,  or  Adenitis— Varieties— Strumous  Enlargement  of 
Glands — Treatment. — Other  Diseases  of  Lymphatics  and  their  Glands 
— L3unphadenoma — Elephantiasis  of  the  Legs  and  Scrotum — Varix  of  the 
Lymphatics .  754-7G1 

I 


Chapter  XL. — Diseases  of  Veins. 

Phlebitis — Idiopathic  and  Traumatic — Pathology — Embolic — Symptoms — 
Treatment  —  Diffuse  Phlebitis — S3miptonis  — Treatment. — Varix  —  Defini¬ 
tion — Appearance — Locality — Causes — Structure — Treatment — Obliteration 

of  Varicose  Veins .  761-768 

VOL.  1. — B 


XVlll 


CONTEXTS. 


PAGE 

Chapter  XLI. — Aneurism  by  Anastomosis;  and  X^vus. 

Aneurism  by  Anastomosis— Xature — Diagnosis— Treatment. — Xa^vus — 
Capillary — Venous  Structure — Treatment — Operations  on — Ligature  of. — 
Xacvi  in  Special  Situations — Scalp — Fontanelle — Face— Eyelids— Xose 
— Cheeks — Lips — Tongue — Penis— Vulva  and  Pudendum — Extremities, 
Neck,  and  Trunk — Xaevoid  Lipoma. — Hemorrhagic  Diathesis— Causes 
— Treatment .  708-78 1 


\ 


LIST  OF  ILLUSTRATIONS  TO  YOL  I. 


FIG. 

1.  Clover’s  chloroform  apparatus  ...... 

2.  AcVBinistration  of  chloroform  by  Clover’s  apparatus 

3.  Lines  of  incision  in  Teale’s  amputation  ..... 

4.  Teale’s  amputation  :  stump  ...... 

5.  Artery  of  thigh-stump  laid  o^Den  ...... 

G.  Nerve  in  a  stump  of  forearm  ...... 

7.  Necrosed  end  of  femur  from  stump  ..... 

8.  Aneurismal  varix  in  a  stump  ...... 

9.  Amputation  of  part  of  a  finger  by  cutting  from  above 

10.  Amputation  of  a  linger.  Cutting  the  flap  by  transfixion 

•11.  Amputation  of  a  finger.  Removing  the  head  of  the  metacarpal  bone  . 

12.  Amputation  of  index  finger.  Removing  the  head  of  the  metacarpal 

bone  ......... 

13,  14,  15.  Results  of  amputation  above  metacarpo-phalangeal  articulation 

in  middle,  index,  and  ring  fingers  .  .  .  .  . 

16.  Amputation  of  the  left  thumb  and  metacarpal  bone 

17.  Amputation  of  right  thumb  by  transfixion.  Cutting  the  anterior  flap  . 

18.  Result  of  amputation  of  the  thumb.  .  .  .  .  . 

19.  Hand  after  amputation  of  metacarpal  bones  and  first  two  fingers 

20.  Hand  after  removal  of  metacarpal  bones  and  three  fingers,  leaving  thumb 

and  little  finger  ........ 

21.  Amputation  at  the  wrist  ....... 

22.  Amputation  of  the  forearm.  Transfixion  of  the  anterior  flap 

23.  Amputation  of  the  arm.  Clearing  the  bone  .... 

24.  Amputation  at  the’shoulder-joint  b}’  transfixion  .... 

25.  Amputation  at  the  shoulder-joint.  Opening  the  capsule,  and  making 

inner  flap  ......... 

2G.  Amputation  at  the  shoulder-joint.  Holding  vessels  in  the  inner  flap 

27.  Stump  after  amputation  at  the  shoulder-joint  .... 

28.  Amputation  at  shoulder  by  Spence’s  method  .... 

29.  Incision  in  amputation  of  a  toe  ...... 

30.  Removal  of  metatarsal  bone  of  great  toe;  flap  formed;  joint  being 

opened  ......... 

31.  Amputation  of  the  great  toe  by  oval  method  .  .  .  . 

32.  Removal  of  metatarsal  bone  of  little  toe  :  flap  formed  :  bone  being 

cleared  ......... 

33.  Line  of  Hey’s  operation  ....... 

34.  Line  of  Chopart’s  operation  ...... 

35.  Chopart’s  operation  :  flap  formed  before  disarticulation  . 

36.  Chopart’s  operation  :  flap  formed  after  disarticulation 

37.  Line  of  amputation  of  great  toe  ...... 

38.  Syme’s  amputation  of  the  foot.  Clearing  the  os  calcis  . 

39.  Syme’s  amputation  of  the  foot.  Anterior  incision  and  disarticulation  . 

40.  Syme’s  disarticulation  at  ankle-joint  •  .  .  .  . 

41.  Syme’s  amputation  of  the  foot.  Sawing  off  the  malleoli. 

42.  Pirogoff’s  amputation  :  application  of  saw  to  os  calcis 

43.  PirogoflTs  amputation  :  appearance  of  parts  after  removal  of  malleoli  . 

44.  Stump  after  Pirogoff's  amputation  ...... 

45.  Amputation  of  the  right  leg.  Transfixion  of  the  posterior  flap  . 


PAGE 

30 

30 

44 

44 

49 

49 

50 

51 
59 
GO 
61 


62 


62 

63 

64 
64 
64 

64 

65 

65 

66 

67 

68 
69 

69 

70 

71 

71 


<  o 

73 

74 
74 

74 

75 

75 

76 
76 
78 
78 
78 
80 


XX  LIST  OF  ILLUSTRATIONS  TO  VOL.  I. 

FIG.  PAGE 

4G.  Amputation  of  the  leg.  Sawing  the  hones  .  .  .  .81 

47.  Amputation  through  the  knee  by  long  anterior  flap  .  .  .82 

48.  Amputation  through  the  condyles  by  long  posterior  flap  .  .  83 

49.  Amputation  at  knee  by  lateral  flaps  .  .  .  .  .84 

50.  Amputation  of  the  lower  third  of  the  thigh  by  lateral  flaps  .  .  85 

51.  Amputation  of  the  thigh  :  entero-posterior  flap  operation  .  .  86 

52.  Amputation  of  thigh  :  formation  of  posterior  flap  by  transflxion  :  of 

anterior,  by  cutting  from  without  inwards  .  .  .  .86 

53.  Lister’s  aorta-compressor  applied  ....  .  .  88 

54.  Amputation  at  the  hip-joint :  formation  of  anterior  flap  in  left  limb  .  88 

55.  Amputation  at  the  hip-joint :  formation  of  anterior  flap  in  right  limb  .  89 

56.  Amputation  at  hip-joint ;  compression  of  femoral  artery  in  anterior 

flap  .........  91 

57.  Irrigating  apparatus  .......  109 

58.  Introduction  of  a  seton  .......  122 

59.  Healthy  pus-cells  ........  123 

60.  Pus-ceils  from  pj-^emic  abscess  ......  124 

61.  Pus-cells  from  scrofulous  abscess  .  .  .  .  .  .124 

62.  Large  lumbar  abscess  extending  down  the  thigh  and  leg  .  .130 

63.  Suction-trocar  ........  132 

64.  Abscess  bistoury  .  .  .  .  .  .  .  .133 

65.  Introduction  of  seton  through  canula  .....  135 

66.  Forked  probe  for  introducing  drainage-tube  .  .  .  .136 

67.  Drainage-tube  and  forked  probe  ......  136 

68.  The  serreflne  ........  171 

69.  Forceps  for  removing  small  pointed  bodies  ...  .  .  187 

70.  Perforation  of  right  femur  by  bullet.  Longitudinal  splitting  of  bone 

(United  States  Army  Museum.)  .....  189 

71.  Gunshot  wound.  Aperture  of  entry  .  .  .  .  .190 

72.  Gunshot  wound.  Aperture  of  exit  .....  190 

73.  Gunshot  wound  of  thigh  ;  mode  of  compressing  artery  temporarily  .  195 

74.  Xelaton’s  probe  ........  196 

75.  76,  77.  Bullet-screw,  forceps,  and  extractor  ....  196 

78.  Bullet-forceps  .  .  .  .  .  .  .  .  196 

79.  Hook  splinter  forceps  .  .  .  .  .  .  .196 

80.  Bullet  in  head  of  humerus  .  .  ...  .  .  203 

81.  Contraction  of  elbow  from  cicatrix  of  burn  of  fourth  degree  .  .  221 

82.  Contraction  of  thumb  from  burn  of  fourth  degree  .  .  .  221 

83.  Dislocation  backwards  of  little  Anger  from  contraction  of  the  cicatrix  of 

a  burn  of  the  fourth  degree  ......  222 

84.  Deformity  of  right  hand  from  burn  of  the  fourth  or  flfth  degree  .  222 

85.  Deformity  of  left  hand  from  burn  of  the  Arth  degree  .  .  .  222 

86.  Deformed  foot  from  burn  of  the  fourth  and  flfth  degrees  .  .  223 

87.  Cicatrix  of  lip  and  neck  before  operation  ....  224 

88.  The  same  patient  after  operation  ......  224 

89.  Incisions  in  Teale’s  operation  for  cicatricial  deformit}^  of  the  lower  lip.  224 

90.  Teale’s  operation  :  the  flaps  in  place  .....  224 

91.  Pressure  with  thumbs.  Application  of  tourniquet  to  femoral  artery  .  238 

92.  Torsion  of  brachial  artery  .  ......  241 

93.  End  of  artery  drawn  forwards.  Application  of  ligature  .  .  247 

94.  Liston’s  “  bull-dog”  forceps  modiflecl  .....  247 

95.  A  reef-knot  .........  248 

96.  Exposure  and  opening  of  the  sheath  .....  249 

97.  Opening  in  the  sheath  :  vessels  exposed  .....  249 

98.  Passage  of  the  needle  and  ligature  .....  250 

99.  Femoral  artery,  fifty-six  hours  after  amputation  .  .  .  .  253 

100.  Brachial  artery,  ten  days  after  amputation  ....  253 

101.  Femoral  arteiy,  six  weeks  after  amputation  ....  253 

102.  Partial  absorption  of  coagulum  in  femoral,  fourteen  days  after  amputa¬ 

tion  .........  254 

103.  Femoral  arteries,  teu  days  after  amputation  of  thigh.  Death  from 

pyaemia  .........  254 

104.  Acupressure.  First  method.  Raw  surface  ....  256 

105.  Acupressure.  First  method.  Cutaneous  surface  .  .  .  256 

106.  xVcupressure.  Second  method  ......  256 


LIST  OF  ILLUSTRATIONS  TO  VOL.  I. 


XXI 


FIG.  PAGE 

107.  Acupressure.  Third  method  ......  257 

108.  Acupressure.  Fourth  method  ......  257 

109.  Anastomosing  circulation  in  sartorius  and  pectineus  of  dog,  three 

months  after  ligature  of  femoral.  (After  Porta.)  .  .  .  201 

110.  Direct  anastomosing  A'essels  of  right  carotid  of  goat,  five  months  after 

ligature.  (After  Porta.)  .  .  ....  261 

111.  Change  in  the  trunk  after  ligature,  "svith  anastomosing  vessel  .  .  261 

112.  Circumscribed  traumatic  aneurism  in  ball  of  thumb  after  a  powder- 

flask  explosion  ........  272 

113.  A  varicose  aneurism  at  the  bend  of  the  arm  unopened  .  .  .  274 

114.  The  same  varicose  aneurism  removed  from  its  connections  .  .  275 

115.  The  same  tumor  laid  open,  showing  the  circumscribed  false  aneurism 

between  the  two  vessels  .......  275 

116.  The  opened  tumor  removed  from  its  connections.  Application  of  liga¬ 

tures  .........  276 

117.  Oblique  and  longitudinal  fractures  .....  304 

118.  Comminuted  fracture  of  the  humerus  without  displacement  .  .  308 

119.  Section  of  fractured  tibia,  four  weeks  after  accident  .  .  .  310 

120.  Starched  bandage  applied  to  fractured  thigh  ....  316 

121.  Seutin’s  pliers  ........  316 

122.  Application  of  Seutin’s  pliers  to  starched  bandage  .  .  .  317 

123.  Starched  bandage  :  trap  left  for  dressing  wound  .  .  .317 

124.  Bavarian  plaster  splint :  adjustment  of  the  flannel  layers  .  .  319 

125.  Gangrene  of  forearm  and  hand  from  tight  bandaging  .  .  .  321 

126.  Apparatus  for  ununited  fracture  of  femur  ....  337 

127.  Archimedean  drill  for  perforating  bone  .....  338 

128.  Gutta  percha  splint :  original  shape  .....  342 

129.  Gutta  percha  splint  moulded  to  shape  of  jaw  ....  342 

130.  Apparatus  applied  to  fracture  of  lower  jaw  ....  343 

131.  Healthy  clavicle  ........  347 

132.  Fracture  of  clavicle,  outside  of  trapezoid  ligament  .  .  .  347 

133.  Apparatus  for  fractured  clavicle  ......  349 

134.  Apparatus  for  fracture  of  the  neck  of  the  humerus  .  .  .  353 

135.  Transverse  fracture  of  humerus.  Separation  of  condj'les  .  .  355 

136.  Paralysis  of  hand  (wrist-drop)  after  fracture  of  humerus  .  .  356 

137.  Permanent  flexure  from  paral3"sis  after  fracture  of  humerus  .  .  356 

138.  Apparatus  for  wrist-drop  after  fracture  of  the  humerus  .  .  357 

139.  Fracture  of  lower  end  of  radius :  side  view  .  .  .  .  359 

140.  Fracture  of  lower  end  of  radius :  hack  view  .  .  .  .  359 

141.  Fracture  of  lower  end  of  radius  :  displacement  of  articular  surface  .  360 

142.  Fracture  of  lower  end  of  radius  :  displacement  of  lower  fragment  .  360 

143.  Nelaton's  apparatus  for  treatment  of  fracture  of  the  lower  end  of  the 

radius  .........  362 

144.  Attitude  of  limb  in  intracapsular  fracture  of  the  neck  of  the  thigh¬ 

bone  .........  367 

145.  Simple  extracapsular  fracture  of  the  neck  of  the  thigh-bone  :  detach¬ 

ment  of  the  trochanter  .......  370 

146.  147.  Section  of  impacted  extracapsular  fractures  of  neck  of  femur : 

showing  the  degree  of  impaction  and  of  splintering  in  different  cases  371 

148.  Union  in  impacted  extracapsular  fracture  of  neck  of  femur  .  .  371 

149.  Impacted  extracapsular  fracture  of  neck  of  femur  ;  abundant  forma¬ 

tion  of  callus  ........  371 

150.  Liston’s  long  splint  .......  375 

151.  Compound  fracture  of  shaft  of  thigh-bone  :  treatment  b}"  bracketed  long 

splint  .........  375 

152.  Fracture  of  shaft  of  thigh-bone  :  treatment  by  weights  and  short  splints  376 

153.  Limb  suspended  from  splint  by  slings,  preparatory  to  application  of 

roller  .........  376 

154.  Impacted  fracture  of  lower  end  of  thigh-bone  ....  378 

155.  156.  Fracture  of  condjTes  from  fall  on  the  bent  knees  .  .  .  378 

157.  Fractured  patella  :  side  view  of  limb,  straight  ....  379 

158.  Fracture  of  patella  :  separation  between  fragments  increased  by  bend¬ 

ing  the  knee  ........  379 

159.  M’Intyre’s  splint,  modified  by  Liston  .....  382 


160.  Salter’s  swing-box  for  fractured  leg  .....  383 


XXll 


LIST  OF  ILLUSTRATIONS  TO  YOL,  I. 


FIG.  PAGE 

161.  Fractures  of  tibia  and  fibula  above  ankle  ....  885 

162.  Pott’s  fracture :  application  of  Dupin^tren’s  splint  .  .  .  387 

163.  Comminuted  fracture  of  astragalus ;  displacement  backwards  .  .  389 

164.  Bandage  applied  for  extension  :  clove-hitch  knot  .  .  .  394 

165.  Dislocation  of  the  clavicle  on  the  acromion  ....  405 

166.  Subglenoid  dislocation  of  the  head  of  the  humerus  .  .  .  407 

167.  Subclavicular  dislocation  of  the  head  of  the  humerus  .  .  .  407 

168.  Subcoracoid  dislocation  of  the  bead  of  tl>e  humerus  .  .  .  407 

169.  Subspinous  dislocation  of  the  head  of  the  humerus  .  .  .  407 

170.  Subcoracoid  dislocation  of  humerus  .....  408 

171.  Subglenoid  dislocation  .......  409 

172.  Reduction  of  dislocated  shoulder-joint  by  the  heel  in  the  axilla  .  411 

173.  Dislocation  of  the  radius  forwards  :  limit  of  power  of  bending  the  arm  417 

174.  Dislocation  of  the  radius  forwards  :  deformity  of  outer  side  of  the 

arm  when  extended  .  .  .  .  .  .  '.417 

175.  Position  of  the  bones  in  an  old  unreduced  dislocation  of  the  radius  for¬ 

wards  .  .  .  .  .  .  .  .  .417 

176.  Dislocation  of  the  ulna :  reduction  .  .  .  .  .419 

177.  Dislocation  of  the  hand  and  carpus  forwards  ....  420 

178.  Dislocation  of  the  nvtacarpus  ;  forwards,  from  the  carpus  .  .  422 

179.  Dislocation  backwards  of  the  proximal  phalanx  of  the  thumb  .  423 

180.  Partial  dislocation  of  the  middle  phalanx  of  the  iniddR  finger  .  424 

181.  Dislocation  of  the  head  of  the  thigh-bone,  according  to  Astley  Cooper’s 

classification.  Upwards,  and  somewhat  backwards,  on  dorsum  ilii  426 

182.  - Backwards  into  sciatic  notch  .  .....  426 

183.  - Downwards  into  foramen  ovale  .....  426 

184.  - Forwards  and  upwards  on  the  pubic  bone  ....  426 

185.  Dislocation  below  the  tendon.  Much  inversion.  (Bigelow.)  .  .  429 

186.  Dorsal  dislocation.  Reduction  by  rotation.  Tlie  limb  has  been  flexed 

and  abducted,  and  it  remains  only  to  evert  it  and  render  the  outer 
branch  of  the  Y -ligament  tense  by  rotation.  (Bigelow.)  .  .  430 

187.  Reduction  of  ilio-sciatic  dislocation  b}"  extension  .  .  .  431 

188.  Dislocation  downwards  and  outwards  towards  the  tuberosity  below 

tendon.  (Bigelow.)  .  .  ...  .  .  .  431 

189.  Thyroid  dislocation.  (Bigelow.)  .....  432 

190.  Reduction  by  manipulation  in  thyroid  dislocation.  Rotation  and  cir¬ 

cumduction  inwards  of  head  of  femur.  (Bigelow.)  .  .  .  432 

191.  Reduction  of  dislocation  into  obtura  or  foramen  by  extension  .  .  433 

192.  Dislocation  directly  downwards.  (Bigelow.)  ....  433 

193.  Dislocation  downwards  and  inwards  towards  perinaeum.  (Bigelow.)  433 

194.  Pubic  dislocation.  (Bigelow.)  ......  434 

195.  Pubic  dislocation.  Head  of  bone  in  groin  suspended  by  Y -ligament. 

(Bigelow.)  ........  434 

^  196.  Reduction  of  pubic  dislocation  by  extension  ....  435 

197.  Subspinous  dislocation.  The  Y -ligament  is  stretched  across  the  neck 

of  the  bone,  which  lies  beneath  it.  (Bigelow.)  .  .  .  435 

198.  Dissection  of  foot  in  compound  dislocation  of  astragalus  outwards  .  444 

199.  Fracture  of  the  skull  from  gunshot  injuiy  from  within  :  splintering  of 

outer  table  .  .  .  .  .  .  .  .  469 

200.  The  same— natural  size  .......  469 

201.  Apparatus  for  fracture  of  spine  ......  505 

202.  Ear-scoop  .........  509 

203.  Split  sheet  applied  :  ends  knotted  ......  530 

204.  Application  of  suture  to  wounded  bowel  ....  555 

205.  Operation  for  lacerated  perinaeum  .....  563 

206.  Obstruction  of  femoral  artery  at  its  bifurcation  by  an  embolon  .  .  568 

207.  Femoral  and  tibial  arteries  obstructed  in  senile  gangrene  .  .  569 

208.  Senile  gangrene  :  exposure  of  bones  of  foot  ....  569 

209.  Senile  gangrene  of  foot :  line  of  separation  ....  572 

210.  Spontaneous  amputation  in  gangrene  of  right  foot  and  left  leg  from 

plastic  arteritis  ........  578 

211.  Temperature  table  in  a  case  of  pyaemia  following  primary  amputation 

of  the  foot  ........  608 

212.  Temperature  table  in  a  rapidly  fiital  case  of  pyaemia  following  a  com¬ 

pound  and  comminuted  fracture  of  the  bones  of  the  leg  .  .  609 


LIST  OF  ILLUSTRATIONS  TO  VOL,  I.  xxiii 


FIG.  , 

213.  Contents  of  sebaceous  tumor :  cliolesterine,  fatty  and  granular  matters 

214.  Horn  on  nose  of  a  child  ....... 

215.  Ulcerated  encysted  tumor  of  scalp  ..... 

21G.  Structure  of  fibroid  tumor  ....... 

217.  Pendulous  fibro-cellular  tumor  ...... 

218.  Myxoma  from  parotid  ....... 

219.  Fusiform  and  oat-shaped  cells  from  myeloid  tumor 

220.  Recurrent  malignant  nasal  polypus ;  spindle-cells.  Myeloid  sarcoma. 

220  diameters  .  .  .  .  .  .  . 

221.  Myeloid  plates  or  plate-like  cells  from  a  tumor  of  the  lower  end  of  the 

femur  ......... 

222.  Fibro-plastic  tumor  springing  from  the  scapula  .  .  .  . 

223.  Cells  from  fibro-plastic  tumor  of  scapula  :  first  recurrence 

224.  Microscopic  characters  of  the  tumor  in  its  second  recurrence.  Multi- 

nucleated  myeloid  cells  ....... 

%/ 

225.  Myeloid  tumor  of  radius  ....... 

220.  Myeloid  tumor  of  the  metacarpal  bones  of  the  index  and  middle  fingers. 

Successful  removal  of  those  bones  and  fingers  .... 

227.  Structure  of  enchondroma  ...... 

228.  Large  enchondroma  of  index  finger  .  .  .  .  . 

229.  Ordinary  enchondroma  of  finger  ...... 

230.  Scirrhus  of  breast ;  showing  cells  and  fibres  .... 

231.  Scraping  from  scirrhus  of  breast  ...... 

232.  Cells  from  encephaloid  of  tongue  (rapidly  recurring).  Magnified  300 

diameters  .....  .  .  .  . 

233.  Cells  from  scirrhus  of  breast  (rapidly  recurring).  Magnified  300  dia¬ 

meters  ......... 

234.  Scirrhus  of  breast,  hardened  in  chromic  acid ;  showing  stroma 

235.  Epithelioma  of  the  lower  lip.  Male,  about  21  . 

230.  Section  of  an  epithelioma  of  the  cheek,  showing  the  formation  of  epi¬ 
thelial  cells  within  the  substance  of  the  true  skin 

237.  Cells  from  epithelial  cancer  of  lower  lip  . 

238.  Cells  from  chimney-sweep’s  cancer  ..... 

239.  Concentric  globes  of  epithelioma  ...... 

240.  Steel  chain  ecraseur  ....... 

241.  Ecraseur  applied  ........ 

242.  Scrofulous  ulcer  of  leg  ....... 

243.  Scrofulous  disease  of  arm  and  finger  .  .  .  .  . 

244.  Diagram  from  Virchow,  of  development  of  tubercle  from  connective 

tissue  in  the  pleura,  showing  transition  from  corpuscles  of  that  tissue 
up  to  the  production  of  tubercle  granules.  The  cells  in  the  middle 
are  undergoing  fatt}’-  degeneration.  300  diameters 

245.  Syphilitic  temporary  teeth  ...... 

240.  Syphilitic  permanent  teeth  ...... 

247.  Syphilitic  onychia  ........ 

248.  Hypertrophy  and  deformity  of  toe-nail  .  .  .  .  . 

249.  Cells  from  lupus  of  the  neck.  Magnified  about  1200  diameters 

250.  Rodent  ulcer :  perforation  of  skull  and  exposure  of  dura  mater 

251.  Cancerous  ulcer  of  the  leg  ...... 

252.  Neuroma  with  nervous  filaments  spread  out  over  tumor 

253.  Application  of  pins  to  varicose  veins  .  ...  . 

254.  Syringe  for  injecting  mevi  ...... 

255.  Diagram  of  the  application  of  nsevus-needles  .  .  .  . 

250.  Diagram  of  nsevus  tied  ....... 

257.  Diagram  of  ligature  of  flat  and  elongated  naevus 

258.  Diagram  of  flat  and  elongated  nsevus  tied  .  .  .  . 

259.  Nsevus  of  lower  lip;  front  view  ...... 

200.  Nsevus  of  lower  lip ;  side  view  .  .  .  .  '  .  ’ 

201.  Large  nsevus  of  upper  lip  :  front  view'  .  .  .  .  . 

202.  Large  nsevus  of  upper  lip :  side  view  .  .  .  .  . 

203.  Nsevus  of  tongue  ........ 


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I  A'  I 


THE 


SCIENCE  AND  ART  OF  SURGERY. 


DIYISION  FIRST. 

FIRST  PRINCIPLES. 


CHAPTER  I. 

GENERAL  CONSIDERATIONS  ON  OPERATIONS. 

By  a  Surgical  Operation  is  meant  a  Manual  or  Mechanical  Process 
undertaken  by  the  Surgeon  for  the  remedy  of  Deformity,  congenital  or 
acquired,  or  for  the  cure  or  relief  of  a  patient  suffering  from  the  effects 
of  Injury  or  Disease,  that  are  incurable  by  constitutional  or  ordinary 
local  treatment,  or  in  which  such  treatment  would  be  too  slow  in  effecting 
the  desired  result. 

A  Surgical  Operation  may  be  necessary  for  the  following  objects: — 

1.  For  Remedying  or  Removing  Congenital  Defects  and  Malforma¬ 
tions  :  as  Harelip,  Clubfoot,  or  Supernumerary  Fingers  or  Toes. 

2.  For  Remedying  Acquired  Defects  and  Deformities :  as  in  the  Clo¬ 
sure  of  Fistulse,  the  Restoration  of  Lost  Parts,  and  the  Correction  of 
Distortions  of  the  Limbs. 

3.  For  the  Removal  of  Foreign  Substances  from  the  Body :  as  in  the 
Extraction  of  a  Bullet  or  a  Calculus. 

4.  For  the  Repair  of  the  Effects  of  Dijuries  :  as  in  the  treatment  of 
certain  Fractures  and  Dislocations. 

6.  For  the  Removal  of  Parts  that  have  been  so  disorganized  by  the 
effects  of  Injury  that  their  vitalit}^  is  lost,  or  that  their  continued  con¬ 
nection  with  the  rest  of  the  body  would  be  a  source  of  danger :  as  in 
Amputation  for  Frost-bite  or  Mangled  Limbs. 

6.  For  the  Removal  of  Diseased  Structures  that  interfere  with  the 
utility  of  an  organ  or  part :  as  in  the  Extraction  of  a  Cataract. 

t.  For  the  Removal  of  Diseased  Sti'uctures  that  seriously  inconveni¬ 
ence  the  patient  or  that  remotely  threaten  life :  as  in  the  Extirpation  of 
Tumors,  Simple  or  Malignant. 

8.  For  Rescuing  a  Patient  from  Immediate  and  Inevitable  Death:  as 
in  Tying  a  Bleeding  Artery,  Opening  the  Windpipe  in  Laryngeal  Ob¬ 
structions,  Relieving  an  Over-distended  Bladder,  or  Dividing  the  Stric¬ 
ture  in  Strangulated  Hernia. 

Manual  dexterity  is  necessarily  of  the  first  advantage  in  the  perform¬ 
ance  of  any  operation,  and  the  Surgeon  should  diligently  endeavor  to 
VOL.  I _ 2 


18 


GENERAL  REMARKS  ON  OPERATIONS. 


acquire  the  Art  of  using  his  instruments  "with  neatness,  with  rapiclit}*, 
and  with  certainty’.  In  many  cases  of  minor  moment,  no  other  requisite 
is  needed  by  the  Surgeon  than  this.  But  it  "would,  indeed,  be  a  fatal 
error  to  suppose  that,  in  the  majority  of  cases  requiring  surgical  inter¬ 
ference,  this  is  the  onl}^  or  indeed  the  chief  requirement  on  the  part  of 
the  operator.  Manual  dexterity  must  not  be  mistaken  for  surgical  skill ; 
and,  desirable  as  it  doubtless  ma}^  be  to  be  able  to  remove  a  limb,  or  to 
cut  out  a  stone,  with  rapidity — important,  in  a  word,  as  it  is  to  become 
a  dexterous  operator — it  is  of  far  greater  importance  to  become  a  suc¬ 
cessful  Surgeon.  The  object  of  every  operation  is  the  removal  of  some 
condition  that  either  threatens  life  or  interferes  with  the  comfort  and 
utility  of  existence;  and  the  more  certainly  a  Surgeon  can  accomplish 
this  object,  the  better  will  he  do  his  duty  to  his  patients,  and  the  more 
successful  will  he  be  in  his  practice.  Success  then,  in  the  result  of  an 
operation,  whether  that  result  be  the  preservation  of  life  or  the  removal 
of  a  source  of  discomfort,  is  the  thing  to  aim  at.  To  this,  dexterity  and 
rapidity  in  operating  are  in  a  high  degree  conducive;  but  there  are 
various  other  considerations  equall^^or  still  more  necessary,  the  solution 
of  which  can  only  be  afforded  by  an  intimate  general  acquaintance  with 
the  Science  of  Surgery  and  of  Medicine.  The  Diagnosis  of  the  nature 
of  the  local  disease,  and  of  the  extent  of  its  connections,  has  to  be  made  ; 
lurking  visceral  affections  must  be  detected  and,  if  possible,  removed. 
The  Constitution  of  the  patient  must  be  prepared;  he  must,  as  far  as 
possible,  be  placed  in  those  hygienic  conditions  which  are  most  favorable 
to  recovery  ;  the  best  time  for  the  performance  of  the  operation  must  be 
seized  ;  and,  after  its  completion,  the  general  health  must  be  attended  to 
in  such  a  way  as  sliall  best  carry  the  patient  through  the  difficulties  he 
has  to  encounter,  and  any  sequelm  or  complications  that  arise  must  be 
subjected  to  appropriate  treatment.  These,  as  well  as  the  simple  per¬ 
formance  of  the  operation,  are  the  duties  of  the  Surgeon  ;  and  on  the 
manner  in  which  they  are  performed,  as  much  as,  or  even  perliaps  more 
than  on  the  mere  manual  dexterity  displa3’ed  in  the  operation  itself,  will 
the  fate  of  the  patient  depend.  It  is  well  knowui  that  the  result  of  ope¬ 
rations  differs  much  in  the  practice  of  different  Surgeons  of  acknowledged 
dexterity’;  and  this  variation  in  the  proportionate  number  of  recoveries 
cannot  be  accounted  for  by  any  difference  in  the  degree  of  manual  skill 
displayed  in  the  operation  itself,  but  must  rather  be  sought  in  the  greater 
attention  that  is  paid  b}^  some  Surgeons  to  the  constitutional  treatment 
of  their  patients  before  and  after  operation,  and  to  their  more  perfect 
:acquaintance  with  the  general  science  and  practice  of  surgery.  Indeed, 
:success  in  operative  surgeiy  depends  gTeatly  upon  tlie  selection  of  proper 
«cases.  The  practice  of  operating  in  notoriously  hopeless  cases  witli  the 
vdew  of  giving  the  patient  what  is  called  a  last  chance,  is  much  to  be 
deprecated,  and  should  never  be  followed.  It  is  by  operating  in  such 
circumstances,  especially’  in  cancerous  diseases,  that  much  discredit  has 
resnlted  to  Surgery;  for  in  a  great  number  of  instances  the  patient’s 
death  is  hastened  by  the  procedure,  which,  instead  of  giving  him  a  last 
chaime,  only’  causes  him  to  be  despatched  sooner  than  would  otherwise 
have  happened.  It  may  truly  be  said  that  a  great  surgical  operation,  in 
its  conception,  its  performance,  and  its  completion,  tests  the  operator’s 
medical  knowledge  as  much  and  in  as  varied  a  manner  as  it  taxes  his 
mannal  skill ;  and  that,  taken  as  a  whole,  it  is  the  highest  development 
of  the  medical  art. 

Caiaditions  Influencing  the  Success  of  Operations. — The  cir- 
cnnistainces  that  mainly’  influence  the  result  of  an  operation,  so  far  as  the 


INFLUENCE  OF  GENERAL  HEALTH. 


19 


reeoveiy  of  the  patient  is  concerned,  ma}"  be  arranged  under  three  heads  : 
1.  Those  that  are  connected  with  the  State  of  the  PatienVs  General 
Health  at  the  time  of  its  performance;  2.  The  Hygienic  Conditions  by 
which  he  is  surrounded  after  it  is  done ;  and  3.  The  Special  Dangers 
connected  with  the  operation  itself. 

1.  The  condition  of  a  patient  that  principal!}^  determines  the  result  of 
an  operation  is  the  State  of  his  General  Health.  Indeed,  success  is  influ¬ 
enced  far  more  by  the  state  of  the  patient’s  constitution  than  by  the 
severity  of  an  operation,  or  by  the  mechanical  dexteritj^  with  which  the 
Surgeon  performs  it.  Veiy  often  we  see  a  patient  carried  off  by  fatal 
disease  supervening  on  some  extremelj'  trifling  operation  (such  as  the 
removal  of  a  small  encysted  tumor),  which  in  itself  ought  in  no  way  to 
endanger  life  were  it  not  that  the  patient’s  constitution  was  at  the  time 
of  its  performance  in  so  unhealthy  a  state  that  the  slightest  exciting 
cause  was  suflEicient  to  call  into  activit}’’  fatal  disease.  So,  also,  it  is  no 
uncommon  circumstance  to  see  one  patient  sink  after  the  most  dexter- 
ousl}^  performed  operation  for  hernia,  stone,  the  ligature  of  an  arteiy,  etc.^ 
owing  to  some  morbid  condition  of  the  blood  or  of  the  S3"stem  that  dis¬ 
poses  to  low  or  diffuse  inflammation ;  whilst  another  ma}'  possibly’  make 
the  most  remarkable  and  rapid  reeoveiy  after  he  has  been  mutilated  with 
but  little  skill.  Independenth"  of  actual  organic  disease,  there  are  certain 
conditions  of  the  bod}"  with  respect  to  the  condition  of  the  nervous 
S3'stem,  the  circulation,  and  the  general  ph3"sical  state,  that  exercise  an 
injurious  influence.  Thus,  persons  of  an  irritable  and  anxious  mind  do 
not  bear  operations  so  well  as  those  of  a  more  tranquil  mental  constitu¬ 
tion.  Those  also  of  a  feeble  and  irritable  habit  of  bod}",  especially 
nervous  and  ly’sterical  women,  with  little  strength  of  circulation,  cannot 
bear  up  against  severe  surgical  procedures  ;  being  apt  to  become  de¬ 
pressed  and  exhausted,  and  to  sink  without  rall3"ing.  Persons  who  are 
overloaded  with  fat  are  not  good  subjects  for  surgical  operations.  In 
them  the  circulation  is  iisuall}"  feeble  ;  the  wound  heals  slowh"  and  is  apt 
to  become  slough}" ;  and  intercurrent  disease  of  a  low  type  often  sets  in. 
Short  of  actual  structural  disease  of  important  organs,  as  the  lungs, 
heart,  or  kidneys,  I  know  no  condition  more  unfavorable  to  success  after 
operations  than  premature  or  excessive  obesity. 

An  individual  of  a  sound  constitution,  that  has  never  been  impaired  by 
excesses  of  any  kind,  whose  habits  have  been  temperate  and  sober,  whose 
diet  has  been  sufficient  and  of  good  quality,  whose  mind  has  never  been 
overstrained  by  the  anxieties  of  business  or  the  labors  of  a  professional 
life,  and  whose  existence  has  been  spent  in  rural  occupations  and  in  the 
pure  air  of  the  country,  is  necessarily  placed  in  a  far  more  favorable 
position  to  bear  the  effects  of  any  mutilation,  whether  it  be  the  result  of 
injury,  or  be  inflicted  by  tlie  Surgeon’s  knife,  than  the  man  of  active  and 
unceasing  business  avocations  or  professional  habits,  whose  nervous 
system  is  exhausted  by  his  anxious  labors ;  and  far  more  so  than  the 
poor  inhabitant  of  a  large  and  densely  peopled  town,  who  has  from 
earliest  childhood  inhaled  an  impure  and  fetid  atmosphere,  whose  scanty 
diet  has  consisted  of  the  refuse  of  the  shops,  or  the  semi-decomposed  offal 
of  the  stalls,  and  whose  nervous  system  has  been  irritated  and  at  the 
same  time  exhausted  in  the  daily  struggle  for  a  precarious  livelihood,  or 
over-stimulated  by  habitual  excesses  in  strong  drinks,  by  which  he  has 
hoped  to  purchase  temporary  forgetfulness  of  the  cares  of  a  sordid  life. 
Though  individuals  with  such  different  antecedents  be  placed  under 
exactly  the  same  hygienic  circumstances  after  the  performance  of  an 
operation,  yet  the  results  will  probably  be  very  dissimilar,  influenced  as 


20 


GENERAL  REMARKS  ON  OPERATIONS. 


they  must  be  by  their  past  rather  than  by  their  present  condition.  In 
the  one  case,  the  inflammation  resulting  from  the  incision,  and  requisite 
for  the  cure  of  the  wound,  will  not  overstep  the  normal  degree  necessary 
for  the  healing  process.  In  the  other  it  maj''  not  attain  to  this,  but, 
assuming  a  low  and  diffuse  form,  may  terminate  in  some  of  those  secon¬ 
dary  affections  which  will  presenth^  be  adverted  to  as  occasioning  death 
under  unfavorablejrygienic  conditions. 

Besides  the  general  state  of  the  patient’s  health,  the  Condition  of  Im¬ 
portant  Organs  must  be  taken  into  consideration.  The  state  of  the 
patient’s  Heart  should  be  carefully  looked  to  before  an  operation  is 
undertaken.  Valvular  disease  of  this  organ,  if  early  or  slight,  need  not 
be  an  obstacle  to  most  operations,  especially  those  of  expediency.  But 
fatty  degeneration  of  the  heart,  as  indicated  by  its  feeble  action,  by 
irregularitj’  and  w^ant  of  power  in  the  circulation,  by  breathlessness,  and 
by  a  distinctly  marked  arcus  senilis,  should  make  the  Surgeon  careful  in 
undertaking  any  operation  attended  with  much  loss  of  blood  or  shock  to 
the  nervous  system.  Such  a  condition  of  heart  is  liable  to  occasion  great 
depression  of  strength,  syncope  and  death — often  sudden — some  da^^s 
after  the  operation.  It  need  not,  however,  be  a  bar  to  its  performance, 
if  the  disease  for  which  it  is  to  be  practised  w’ould  otherwise  be  fatal. 

Disease  of  the  Lungs,  of  a  phthisical  character,  when  active  or 
advanced,  is  incompatible  with  the  success  of  an  operation ;  but  under 
certain  circumstances,  as  will  be  explained  wiien  speaking  of  diseases  of 
the  joints  and  flstula  in  ano, an  operation  is  justifiable  and  proper,  even 
though  the  patient  be  consumptive. 

If  the  Liver  be  diseased  organicall}",  if  it  be  in  a  state  of  amyloid 
degeneration,  or  affected  by  cirrhosis,  and  more  especiall}^  if  any  ascitic 
symptoms  haA^e  supervened,  no  operation  but  for  the  relief  of  disease 
that  instantly  threatens  life  should  be  undertaken. 

Perhaps  the  most  serious  constitutional  affection,  and  the  one  that 
more  than  any  other  militates  against  the  success  of  an  operation,  is  a 
diseased  state  of  the  Kidneys,  wdiether  it  assume  the  form  of  albuminuria 
or  of  diabetes  ;  in  these  conditions,  the  local  inflammatory  action  that  is 
set  up  is  apt  to  run  into  a  low,  diffuse,  and  sloughing  form,  and  this  is 
especially  the  case  in  all  operations  about  the  genito-urinaiy  organs. 

The  contamination  of  the  patient’s  system  by  Malignant  Disease  must 
alwa3"S  prevent  our  operating,  as  a  speedy  return  of  the  affection  will 
most  certainly  take  place.  And,  lastly,  no  operation,  save  of  the  most 
urgent  necessit}",  and  to  rescue  the  patient  from  immediate  death,  as  for 
the  suppression  of  arterial  hemorrhage,  should ‘ever  be  performed  whilst 
he  is  laboring  under  P^^aemia,  Septaemia,  Eiysipelas,  Phlebitis,  or  an}^ 
Diff'use  Inflammation ;  and  even  during  the  epidemic  prevalence  of  these 
affections,  operations  that  are  not  of  immediate  necessit}^  should  be  post¬ 
poned  until  a  more  favorable  season.  Operations  in  very  old  people,  if 
severe  and  attended  by  much  shock  to  the  system,  are  commonly  fatal; 
amputations  in  individuals  above  the  age  of  seventy",  are  veiy  rarel}'' 
successful. 

2.  The  result  of  an  operation,  though  greatl}"  dependent  on  the  state 
of  the  patient’s  constitution  at  the  time  of  its  performance,  is  also  mate¬ 
rially  influenced  hy  the  Hygienic  Conditions  to  which  he  is  afterwards 
subjected.  The  conditions  wdiich  chiefl}^  militate  against  the  success  of 
an  operation,  are  bad  or  insufficient  diet,  the  exposure  of  the  patient  to 
the  influence  of  contagious  miasmata,  and  more  particular!}'  the  over¬ 
crowding  of  the  sick  and  wounded,  Avhich  gives  rise  to  an  impure  state 
of  the  atmosphere,  productive  of  the  most  fatal  consequences. 


OVERCROWDING  TO  BE  AVOIDED. 


21 


The  proper  regulation  of  the  patient’s  diet  before  and  after  an  opera¬ 
tion  is  of  great  consequence.  On  this  point  it  is  impossible  to  lay  clown 
any  very  definite  rule,  as  much  depends  not  only  on  the  patient’s  previous 
habits  of  life,  but  on  the  nature  of  the  operation  itself;  and,  as  this  sub¬ 
ject  will  be  discussed  at  the  end  of  the  Chapter,  it  need  not  detain  us 
here.  It  is  not,  however,  often  that  in  civil  practice  the  insufficient 
quantity  or  the  bad  quality  of  the  patient’s  food,  with  which  he  is  sup¬ 
plied  after  the  performance,  influences  materially  the  result  of  an  opera¬ 
tion.  Blit  in  military  and  naval  practice  the  case  is  far  diflerent'.  The 
soldier  or  the  sailor  on  active  service  is  often  exposed  to  serious  injuries 
that  necessitate  the  more  important  operations  at  a  time  when  his  con¬ 
stitutional  powers  have  already  been  broken  down  by  scurvy,  dysenteiy, 
or  some  other  similar  affection,  resulting  not  so  much  from  the  deficient 
quantity  as  from  the  unwholesome  character  of  the  food  with  which  alone 
he  can  be  supplied.  And  after  the  operation  his  only  available  nutri¬ 
ment  may  be  of  the  coarsest  character,  possibly  salted,  and  imperfectly 
cooked.  In  such  circumstances  operation-wounds  do  not  heal,  or  they 
assume  a  peculiar  gangrenous  character ;  or  the  patient  sinks  from  ulce¬ 
ration  of  the  intestinal  mucous  membrane.  The  mortality  of  operations 
becomes  enormously  increased  ;  and  there  can  be  little  doubt  that  thou¬ 
sands  of  deaths  which  have  occurred  in  wars  between  the  most  civil¬ 
ized  nations  and  the  best  appointed  armies  may  be  attributed  to  these 
causes. 

The  exposure  of  a  patient  after  an  operation  to  contagious  emanations 
from  other  sick  or  wounded  patients,  may  be  attended  b^^  the  most 
fatal  consequences.  Whenever  it  is  practicable,  every  case  of  pyiemia, 
erysipelas,  inflamed  absorbents  or  veins,  or  hospital  gangrene,  should 
be  rigorously  excluded  from  the  same  ward  or  room  in  which  other 
patients  with  operation-wounds  happen  to  be  lying ;  and,  if  possible,  the 
same  nurses,  dressers,  or  surgeons  should  not  be  allowed  to  go  from  the 
infected  to  the  healthy,  nor  should  the  same  dressings  or  sponges  be  ever 
used  for  both.  Every  Hospital  Surgeon  must  have  had  abundant  occasion 
to  deplore  many  deaths  after  operation,  arising  from  preventable  causes 
due  to  want  of  attention  to  these  precautions. 

Perhaps  there  is  no  hygienic  condition  of  greater  importance,  so  far  as 
the  results  of  operations  are  concerned,  than  the  avoidance  of  the  over¬ 
crowding  of  operation-cases  or  of  injured  persons  in  one  ward  or  build¬ 
ing  ;  more  particularly  if  the  wounds  be  in  a  suppurating  state.  In  these 
circumstances,  the  atmosphere  becomes  loaded  with  animal  exhalations 
in  a  state  of  putrescence  or  fermentation.  These  are  either  absorbed  by 
the  lungs  and  skin,  or  the  pulmonary  and  cutaneous  surfaces  are  unable 
to  set  free  their  excreta  in  an  atmosphere  already  surcharged  ;  the  blood 
becomes  thereby  vitiated,  and  low,  diffuse,  or  erysipelatous  inflammations 
of  all  kinds,  with  p3"8emia,  septmmia,  or  sloughing  phagedsena,  are  the 
necessaiy  consequences.  In  fact,  these  diseases  ma^^,  if  the  term  is 
allowable,  be  manufactured  in  any  hospital  or  house,  however  clean  and 
well  situated,  by  the  accumulation  within  it  of  too  large  a  number  of 
patients  suffering  from  suppurative  fever.  The  two  great  conditions  to 
be  attended  to  in  the  prevention  of  overcrowding  are  :  (1)  Sufficient 
cubic  space  for  each  patient ;  and  (2)  An  efficient  system  of  ventilation. 
Both  conditions  are  equally  necessary.  The  space  afforded  to  each 
patient  in  the  surgical  ward  of  an  hospital  where  patients  with  suppu¬ 
rating  wounds  are  mixed  with  others  suffering  from  such  injuries  as 
simple  fractures,  unattended  by  breach  of  surface,  should  be  at  least 
1500  cubic  feet,  and  this  should  be  changed  by"  ventilation,  once,  if  not 


22 


GENERAL  REMARKS  ON  OPERATIONS. 


twice,  in  the  hour.  If  the  proportion  of  simple  cases  be  great,  less  than 
this  may  be  safe  ;  but  if  the  majorit}"  of  the  patients  have  suppurating 
wounds,  more  space,  as  much  even  as  2000  cubic  feet,  should,  if  possible, 
be  allowed.  Whenever  we  have  had  an  outbreak  of  the  low  surgical 
inflammations — of  eiysipelas,  sloughing  phagedoena,  or  p3"8emia — in  the 
wards  at  Universit}'  College  Hospital,  it  has  been  owing  to  the  accidental 
and,  perhaps,  unavoidable  accumulation  of  a  large  number  of  serious 
injuries  or  of  operation-cases  in  one  ward,  so  that  the  cubic  space  for 
patient’s  has  become  reduced  materially  below  the  figures  above  stated. 
Xot  only,  however,  is  space  required,  but  change  of  air^  by  proper  ven¬ 
tilation^  is  equally  needful.  For,  however  large  the  cubic  space  for 
patients,  the  air,  if  not  changed  rapidly  enough,  soon  becomes  loaded 
with  animal  exhalations,  and  highlv  insalubrious.  Hence  care  should 
be  taken  that  a  free  current  of  pure  air  through  the  ward  be  maintained 
day  and  night.  It  is  from  want  of  this  precaution,  during  night  espe- 
ciall}',  that  much  mischief  often  results.  The  importance  of  maintaining 
efficient  ventilation  during  night,  and  the  little  danger  to  be  apprehended 
from  the  admission  of  cold  night  air,  have  been  so  forcibly  pointed  out 
by  M  iss  Nightingale  in  her  Notes  on  Nursing^  and  are  now  so  universally 
admitted,  that  I  need  not  do  more  than  to  add  the  testimony  of  m3"  expe¬ 
rience  to  the  truth  of  her  observations.  In  cold  weather,  also,  there  is 
so  great  a  disposition  on  the  part  of  nurses  and  patients  to  shut  up 
wards  and  rooms,  that  the  air  becomes  close,  oppressive,  and  contami¬ 
nated  ;  and  hence  it  is  that  the  eiysipelatous  and  miasmatic  diseases  are 
so  rife  during  winter  and  earh"  spring.  The  “  East  Wind”  is  commonly 
accused  of  being  the  cause  of  these  ;  and  no  doubt  it  is  so,  but  onl3" 
indirectl}",  b}-  causing  windows  and  doors  to  be  shut,  so  as  to  exclude 
the  cold  that  usuall}"  accompanies  that  wind,  and  thus  rendering  the 
atmosphere  impure.  It  is  impossible  to  over-estimate  the  importance  of 
a  free  supplj-  of  pure  air  in  lessening  the  mortalit}"  after  operations,  not 
onl}"  in  hospitals,  but  equall}"  in  private  dwellings.  Hence  it  is  that 
operations  are  more  successful  when  performed  on  the  health}^  inhabi¬ 
tants  of  the  countiy  than  on  those  whose  lives  have  been  spent  in  the 
close  and  vitiated  atmospheres  of  towns.  And  to  the  same  cause  ma}"  be 
ascribed  the  exemption  of  small  countiy  or  “  Cottage  Hospitals”  from 
those  evil  influences  that  infect  the  best  constructed  establishments  of  a 
similar  kind  situated  iu  large  towns.  Hence,  also,  the  fact  that  has  so 
often  been  observed  in  militaiy  practice,  and  which  the  recent  Franco- 
Prussian  War  has  brought  into  strong  relief — that  those  wounded  fare 
best  who  are  treated  in  open  huts  or  tents,  whilst  those  who  are  placed 
in  the  apparenth’  more  favorable  conditions  afforded  b}"  regular  houses 
become  decimated  b}"  those  scourges  of  militaiy  surgical  practice,  P3"8emia 
and  hospital  gangrene.  It  is  therefore  obvious,  that  the  performance  of 
operations  in  close  and  ill-ventilated  rooms,  or  in  houses  situated  in  over¬ 
crowded,  badl}"  drained  neighborhoods,  should,  as  far  as  possible,  be 
avoided,  and  the  patient  placed  in  more  favorable  h3"gienic  conditions. 

The  mortalit}*  arising  from  inattention  to  these  various  hygienic  con¬ 
ditions  is  not  a  necessit}*  of  the  operation,  but  rises  or  falls  according 
as  the  circumstances  in  which  the  patient  is  placed  depart  more  or  less 
widel3"  from  those  conditions  that  are  necessaiy  to  the  maintenance  of 
health.  It  is  1)3’  the  induction  of  p3’8emia  and  of  the  er3’sipelatous  in¬ 
flammations,  with  fever  of  a  low  t3’pe,  that  the  neglect  of  the  hygienic 
conditions  of  operated  patients  destroys  life.  The  prevalence  of  these 
diseases  in  a  localit3’  or  an  institution  is  the  measure  of,  and  in  direct 


CAUSES  OF  DEATH  AFTER  OPERATION. 


23 


proportion  to,  the  deteriorated  constitutions  of  the  inhabitants,  and  the 
breach  of  sanitary  laws. 

3.  The  Special  Conditions  directly  excited  by  the  Operation  itself 
(though  predisposed  to  by  the  circumstances  that  we  have  just  been 
considering)  and  which  commonly  lead  to  a  fatal  result,  of  which  they 
are  the  immediate  occasion,  are  the  following:  Shock,  Exhaustion, 
Hemorrhage,  Gangrene,  Tetanus,  Internal  Inflammation  of  an  acute 
kind,  PY[emia,  and  the  various  Low,  Diffuse,  and  Erysipelatous  Inflam¬ 
mations.  These  causes  of  death  are  so  various,  and  comprise  so  many 
distinct  diseases,  that  I  shall  do  little  more  here  than  mention  them  ; 
referring  the  reader  to  the  different  Chapters  in  the  Bodj^  of  the  Work, 
in  which  each  is  specially  treated. 

The  Shock  of  an  Operation  may  prove  fatal  in  various  ways  :  from 
the  severity  of  the  mutilation,  as  in  a  case  of  double  amputation  ;  from 
the  nervous  centres  being  implicated,  as  in  the  removal  from  the  face  of 
large  tumors  that  have  connections  with  the  base  of  the  skull ;  from  fear, 
or  from  the  state  of  nervous  depression,  into  which  the  patient  has  pre¬ 
viously  fallen,  causing  liim  to  feel  the  influence  of  an  operation  dispro¬ 
portionately  to  its  severity.  These  various  effects  of  shock  have, 
however,  been  much  lessened  since  aiifesthetics  have  been  generally 
administered  in  operative  surgery.  Anesthesia,  however,  does  not 
remove  the  physical  impression  produced  on  the  system  b}’’  a  severe 
mutilation;  hence  the  influence  of  a  serious  and  prolonged  operation  is 
still  manifested  in  the  production  of  shock,  of  collapse,  and  of  slow 
recovery,  even  though  the  patient  have  suffered  no  actual  pain.  Certain 
operations  appear  to  exercise  a  peculiar  depressing  effect  on  the  nervous 
system,  even  though  no  pain  be  experienced.  Thus,  in  castration,  at 
the  moment  of  the  division  of  the  spermatic  cord,  I  have  often  observed 
the  pulse  to  sink  markedly,  even  though  the  patient  have  been  fully 
anaesthetised.  So  much  is  this  the  case,  that  it  is  well  at  that  moment 
to  suspend  the  administration  of  the  chloroform. 

E xhaustion ^v^ithont  an}’’ tangible  local  or  constitutional  disease,  is  an 
occasional  cause  of  death  after  severe  operations  ;  more  particularly  in 
delicate  females,  in  feeble  or  debilitated  subjects,  or  in  those  who  have 
lost  much  blood. 

Hemorrhage.^  if  very  copious,  may  destroy  the  patient  by  inducing 
syncope  that  may  be  immediately  fatal ;  or  by  increasing  the  influence 
of  the  shock  so  that  he  cannot  rally  ;  or  it  may  be  followed  by  serious 
after-consequences,  such  as  the  supervention  of  hemorrhagic  or  irrita¬ 
tive  fever,  and  a  disposition  to  the  occurrence  of  low  and  erysipelatous 
inflammations.  It  is  in  these  secondary  and  indirect  effects  that  the 
great  danger  of  excessive  hemorrhage  lies.  Patients  who  have  lost 
much  blood  make  slow  recoveries,  often  interrupted  by  intercurrent 
diseases ;  and  not  unfrequently  die  at  the  end  of  two  or  three  weeks, 
from  some  asthenic  visceral  complication.  In  fact,  it  is  in  this  way, 
rather  than  from  its  immediately  dangerous  consequences,  that  the  loss  of 
a  large  quantity  of  blood  at  an  operation  proves  injurious  to  the  patient. 
When  hemorrhage  occurs  a  few  hours,  or  a  day  or  two,  after  an  opera¬ 
tion,  it  usually  proceeds  from  imperfect  ligature  of  the  vessels,  or  from 
arteries  bleeding  after  the  setting-in  of  reaction,  which  had  not  furnished 
blood  whilst  the  patient  was  under  the  influence  of  the  shock  of  opera¬ 
tion.  On  recovery  from  chloroform  also,  it  not  unfrequently  happens 
that  arteries  begin  to  spout,  which  yielded  little  or  no  blood  whilst  the 
patient  was  in  a  state  of  anesthesia.  In  these  circumstances,  hemor¬ 
rhage  is  of  far  less  moment,  and  less  frequently  fatal,  than  when  it 


24: 


GENERAL  REMARKS  ON  OPERATIONS. 


occurs  at  a  later  period,  in  consequence  of  some  morbid  condition  of 
the  wound  or  s^-stem,  and  usuall3^  in  association  with  a  t^q^hoid  state, 
b}’’  which  the  proper  formation  of  plastic  matter  is  interfered  with. 
During  the  performance  of  an  operation,  hemorrhage  should,  as  much 
as  possible,  be  prevented  ;  the  operation  itself  is  a  cause  of  depression, 
and  an\"  great  loss  of  blood  not  onl}’  seriously’  aggravates  this,  but  dis¬ 
poses  to  the  after-occurrence  of  pj’mmia  and  low  inflammations. 

The  Performance  of  an  Operation  during  the  existence  of  any  Acute 
Inflammation^  as  of  a  joint,  for  instance,  is  alwa^^s  attended  l\y  great 
danger :  more  especiall}",  if  the  disease  be  an  inflammation  of  a  low  form, 
as  phlebitis  or  erysipelas.  So  great  is  the  danger  of  performing  an}’-, 
even  the  most  trifling  operations,  in  cases  of  this  kind,  that  the}-  never 
should  be  undertaken,  except  such — the  ligature  of  a  bleeding  vessel  for 
instance — as  may  be  imperatively  required  for  the  immediate  preser¬ 
vation  of  life.  The  danger  in  these  cases  is  from  the  supervention  of 
pyaemia.  This  appears  to  be  occasioned  by  the  blood,  in  such  cases, 
being  loaded  with  a  quantity  of  effete  materials,  which  run  into  a  state 
of  disorganization  under  the  influence  of  the  new  inflammatory  action 
set  up  by  the  operation. 

Gangrene  is  not  a  common  cause  of  death  after  operations.  In  some 
cases  of  amputation,  however,  it  may  occur  in  the  stump;  after  the 
operation  for  strangulated  hernia,  in  consequence  of  the  constriction  of 
the  gut ;  or  in  any  wound^  in  its  contagious  form  of  sloughing 
phagedaena. 

Tetanus  but  rarely  occasions  death  after  operations  in  this  country. 
When  it  does  occur,  it  is  more  frequently  after  the  lesser  than  after  the 
greater  operations  that  it  develops  itself. 

Internal  Inflammations  of  an  acute  and  active  character  may  carry 
off  the  patient  after  an  operation  in  two  ways.  Inflammation  of  this 
kind  may  have  existed  antecedently  to  the  operation,  being  the  disease 
for  which  it  is  performed  ;  and,  being  unchecked  by  the  operation,  may 
continue  its  course  and  destroy  life.  Thus,  when  a  child  dies  after  tra¬ 
cheotomy  for  croup,  death  is  not  in  general  occasioned  by  the  operation, 
but  by  the  extension  of  the  disease  for  which  it  has  been  performed. 
Or  the  inflammation  may  be  the  necessary  and  direct  consequence  of  the 
operation ;  as  when  peritonitis  occurs  after  the  operation  for  strangu¬ 
lated  hernia,  or  arachnitis  after  the  skull  has  been  trephined.  But  it  is 
not  by  the  action  of  any  of  these  direct  results  that  an  operation  usually 
proves  fatal.  In  the  great  majority  of  instances,  death  is  occasioned  in  a 
more  indirect  manner  by  the  development  of  pyaemia,  or  of  some  of  those 
low  and  erysipelatous  inflammations  which  are  allied  to  it,  and  to  which 
a  neglect  of  hygienic  laws  acts  as  a  powerful  predisposing  cause. 

Pydemia  \s>  certainly  the  most  frequent  cause  of  death  after  operations, 
more  particularly  in  large  towns.  It  is  especially  and  directly  predis¬ 
posed  to  by  the  neglect  of  hygienic  laws  by  the  patient  previously  to 
the  operation,  and  by  the  unfavorable  sanitary  conditions  by  which  he 
may  be  surrounded  after  its  performance.  Closely  allied  to  pymmia, 
frequently  coexisting  with  it,  having  the  same  predisposing  causes,  and 
associated  with  febrile  disturbance  of  an  asthenic  type  are  the  various 
low  and  diffuse  in fl animation assuming  the  form  of  erysipelas, 
of  phlebitis,  or  of  inflammation  of  the  absorbents,  which  are  the  dread 
of  surgeons  and  the  scourge  of  hospitals.  It  is  to  pyaemia,  and  to  these 
various  allied  erysipelatous  and  low  inflammations,  with  their  attendant 
asthenic  constitutional  disturbance,  that  at  least  three-fourths  of  the 
deaths  after  operations  are  due.  It  is  in  the  production  of  these 


PREPARATION  FOR  OPERATION. 


25 


diseases  that  an  impure  blood,  loaded  with  effete  materials  retained 
through  habitual  disregard  of  the  ordinary  rules  of  health  or  through 
defective  elimination  by  the  kidne3’s  and  skin,  acts  as  a  potent  predis¬ 
posing  cause,  requiring  but  some  injuiy  or  wound  to  call  into  activity'  a 
most  dangerous  amount  of  local  inflammation  and  of  constitutional  clis- 
turbance.  In  these  circumstances,  it  is  not  the  extent  or  size  of  the 
w’ound  that  determines  the  dangerous  results.  The  mere  fact  of  a 
breach  of  surface,  however  trivial,  is  sufficient  to  excite  these  morbid 
processes,  the  materials  for  which  have  been  previonsl}’ stored  up  in  the 
system.  In  such  conditions  of  the  s}’stem,the  amputation  of  a  toe  ma^" 
be  as  fatal  as  that  of  the  thigh,  or  the  removal  of  a  small  scalp-atheroma 
as  the  ablation  of  the  breast ;  the  onl}"  additional  danger  essentially" 
connected  with  the  greater  operations  being  the  increased  risk  from 
shock  and  hemorrhage. 

Diphtheritic  Inflammation  may-  develop  in  a  wound  with  or  without 
concomitant  throat  affection.  It  maybe  developed  by  direct  contagion, 
or  under  the  influence  of  those  local  epidemics  or  constitutional  influences 
that  cause  diphtheria  to  appear  in  the  fauces.  When  a  wound  becomes 
affected  in  this  way’,  the  edges  and  the  integument  for  some  little  dis¬ 
tance  around  are  swollen,  brawny-,  and  of  a  deep  red  color;  the  surface 
of  the  wound  is  covered  with  a  graydsh-white  exudation  which  cannot  be 
cleaned  off;  the  skin  immediately- contiguous  to  the  wound  also  becomes 
besmeared  with  tenacious  creamy-dooking  exudation  matter;  and  febrile 
sy-mptoms  of  a  low  tyqoe  develop  themselves. 

Preparation  for  Operation. — The  Surgeon,  being  convinced  of  the 
necessity  of  having  recourse  to  operation,  should  fully  and  unreservedly 
lay  before  his  patient  the  state  of  the  case,  and,  if  necessary",  give  the 
reasons  that  render  an  operation  imperative,  in  order  to  obtain  his  consent 
and  that  of  his  family-.  In  the  event  of  the  })atient  refusing  to  submit, 
what  course  should  the  Surgeon  pursue?  In  this  he  must  be  guided 
partly  by  the  nature  of  the  proposed  operation  ;  and  partly-  by  the  state 
of  the  patient,  and  his  capability^  of  forming  a  correct  judgment  of  his  case. 
If  the  operation  be  one  of  expediency,  merely^  for  the  relief  of  an  infir¬ 
mity  or  the  removal  of  an  ailment  which  does  not  directly  jeopardize 
life,  most  certainly  no  Surgeon  would  think  of  undertaking  it  without 
the  full  consent  of  his  patient.  If,  on  the  other  hand,  it  be  an  operation 
that  is  imperatively"  necessary  for  the  preservation  of  life,  in  which  the 
delay-  of  a  few  minutes  or  hours  may-  be  fatal  to  the  patient,  as  in  the 
case  of  the  proposed  ligature  of  a  bleeding  artery,  or  the  relief  of  a 
strangulated  hernia,  and  where  the  patient,  unaw’are  of,  or  incapable  of 
being  made  to  understand,  the  necessity''  for  immediate  action,  is  nn- 
wdlling  to  assent  to  the  proposal,  the  Surgeon  will  truly  be  placed  in  a 
dilemma  of  anxious  responsibility ;  between  allowing  the  patient  to  fall 
a  sacrifice  to  his  ignorance  or  timidity-,  and  attempting,  perhaps  unsuc¬ 
cessfully-,  to  rescue  him  from  inevitable  death  against  his  own  consent. 
I  believe  the  proper  course  for  the  Surgeon  to  pursue  under  such  circum¬ 
stances,  is  to  judge  for  the  patient  in  a  matter  on  which  he  is  clearly 
unable  to  form  an  opinion,  and  to  compel  him,  so  far  as  practicable,  to 
submit  to  the  necessary  steps  for  the  preservation  of  his  life,  or  to  put 
him  under  chloroform,  and,  when  he  is  anesthetized,  to  perform  any 
operation  that  may  be  necessary-.  In  the  event  of  the  patient  being 
insensible,  as  after  an  injury-  of  the  head,  the  Surgeon  must  necessarily 
take  upon  himself  to  act  as  the  case  requires.  Children  cannot  be  con¬ 
sidered  capable  of  giving  an  opinion  as  to  the  propriety  of  an  operation  ; 
the-consent  of  the  parents  is  here  necessary-,  and  quite  sufficient;  and, 


26 


GEXEEAL  REMARKS  ON  OPERATIONS. 


in  their  absence,  the  case  being  an  urgent  one,  the  Surgeon  must  stand 
in  loco  parentis^  and  take  all  responsibilit}^  upon  himself. 

These  points  then  having  been  determined,  the  patient  should,  if  pos¬ 
sible,  be  Prepared  for  the  Operation.  In  a  great  number  of  cases  re¬ 
quiring  operation,  as  in  strangulated  hernia,  bad  compound  fracture,  etc., 
no  time  is  allowed  for  preparation,  but  the  Surgeon  must  at  once  submit 
the  patient  to  the  knife,  whatever  the  state  of  his  constitution  may  be. 
But  in  the  more  chronic  cases,  time  is  given  for  improving  the  constitu¬ 
tion.  This  preparation  must  not  consist  in  any  routine  s3'Stem  of 
purging  and  starving,  which  is  ill  calculated  to  support  the  constitution 
against  the  call  that  will  be  made  upon  its  powers ;  nor,  on  the  other 
hand,  in  a  tonic  or  stimulating  regimen,  which  maj^  produce  fever  and 
irritate  the  constitution  ;  but  in  adapting  our  means  to  the  condition  of 
the  patient  and  the  nature  of  the  operation  to  be  performed.  The  ten- 
denc}"  to  eiysipelas,  pymmia,  and  low  and  diffuse  inflammations  gener¬ 
ally',  is  materially'  lessened  by'  supporting  the  patient’s  strength,  by 
means  of  a  nutritious  diet,  previously^  to  the  performance  of  the  opera¬ 
tion.  Indeed,  in  many  of  the  more  severe  cases  of  compound  fracture 
and  disease  of  the  joints,  it  is  only  by^  the  use  of  a  nutritious  diet,  and 
by'  the  administration  of  tonics,  quinine,  or  iron,  and  stimulants,  often 
in  large  quantities,  that  the  patient  can  be  brought  into  a  condition  to 
bear  the  shock  and  consequent  depression  of  the  operation.  This  is 
more  particularly'  the  case  with  hospital  patients  of  bad  constitution, 
who  have  met  with  serious  accidents,  attended  by  much  suppuration 
and  irritative  fever.  In  the  more  chronic  cases,  the  time  should  be 
seized  for  the  operation  when  the  secretions  are  free,  the  tongue  clean, 
and  the  action  of  the  skin  and  kidney's  in  a  healthy'  state ;  and,  above 
all,  the  mind  should  be  kept  tranquil  and  hopeful,  being  allowed  to 
dwell  as  little  as  possible  upon  the  impending  event.  In  many  opera¬ 
tions,  as  those  on  the  rectum  and  urinary  organs,  or  in  those  of  a  plastic 
character,  special  modes  of  preparation  are  required,  which  will  be  dis¬ 
cussed  when  we  come  to  treat  of  the  operations  in  detail. 

The  Immediate  Preparations  for  the  operation  should  always  be  su¬ 
perintended  by' the  Surgeon  himself.  He  must  see  that  the  table  is  solid, 
and  of  a  convenient  height,  well  covered  with  blankets,  and  provided 
with  pillows;  and  that  the  light  of  the  room  is  good.  There  must  be  a 
sufficient  supply' of  sponges  and  of  basins,  with  hot  and  cold  water; 
and,  if  the  operation  be  likely  to  be  attended  by'  much  hemorrhage,  a 
tray'  filled  with  sand  or  sawdust  should  be  provided,  in  order  to  catch 
the  blood.  The  Surgeon  must  then  look  over  his  instruments,  com¬ 
paring  them,  if  the  operation  be  complicated,  with  a  list  previously’’ 
made  out;  he  must  see  that  they'  are  arranged  in  the  order  in  which  they' 
are  wanted,  and  properly'  covered  with  a  towel.  Much  of  the  successful 
performance  of  an  operation  depends  on  the  attention  and  steadiness  of 
the  assistants.  Of  these  there  should  be  enough,  but  not  too  many'. 
In  all  capital  operations  three  or  four  will  be  required ;  one  for  the  ad¬ 
ministration  of  the  anmsthetic,  another  to  command  the  artery',  a  third 
immediately^  to  assist  the  Surgeon,  and  the  fourth  to  hand  sponges,  in¬ 
struments,  etc.  The  duties  of  the  assistants  should  be  performed  in 
silence,  and  each  man  must  carefully’  attend  to  his  own  business,  and 
not  neglect  this,  as  is  too  often  done,  in  his  anxiety  to  crane  over  and 
see  what  the  Surgeon  is  about.  There  should  be  no  unnecessary'  talking 
when  once  the  patient  is  on  the  table;  the  Surgeon’s  directions  ought 
to  be  conveyed  by  a  brief  word  or  two,  by'  a  look,  or  by'  a  sign  with  the 
hand. 


ANAESTHETICS  IN  SURGERY. 


27 


The  Surgeon  himself  must  always  feel  the  heavy  responsibility  that 
hangs  over  him  during  the  performance  of  a  great  operation — “at  that 
moment  when,”  as  Dr.  Grant  has  elegantly  said,  “  Death  everywhere 
surrounds  his  knife  as  he  is  endeavoring  to  convey  all  his  knowledge  to 
its  point.”  But  having  carefully  considered  each  successive  step  of  the 
operation,  provided  for  every  emergency  that  can  by  any  possibility 
arise  in  the  course  of  it,  and  trusting  in  Him,  from  whom  all  knowdedge 
is  derived,  to  strengthen  his  judgment  and  guide  his  hand  aright,  he 
will  proceed  to  the  performance  of  his  duty  with  self-reliance,  and  in 
the  full  confidence  of  being  able  to  effect  all  that  Art  can  accomplish. 

Employment  of  Anaesthaetics. —  It  is  reasonable  to  believe  that 
the  prev'ention  of  pain  in  surgical  operations  has  been  an  object  of  so¬ 
licitude  to  Surgeon  as  well  as  to  patient  from  the  earliest  ages :  and 
there  can  be  little  doubt  that  narcotics  of  various  kinds  have  at  different 
times  been  employed  with  this  view.  But  the  effect  of  these  was  so  un¬ 
certain — their  after-consequences  perhaps  so  injurious — that  no  perma¬ 
nent  reliance  was  placed  upon  them.  The  first  endeavor  to  induce 
anmsthesia  by  the  inhalation  of  vapors  is  stated  to  have  been  made  in 
the  thirteenth  centuiy  by  Theodoric,  who  recommended  that  a  “  Spongia 
Somnifera,”  impregnated  with  spirituous  extracts  of  various  narcotic 
substances,  should  be  held  to  the  nostrils  till  sleep  was  induced ;  and 
that  after  the  operation  the  patient  should  be  roused  by  tlie  use  of  vine¬ 
gar  or  fenugreek.  It  was  not,  however,  till  the  commencement  of  this 
century  that  any  serious  attempts  were  made  in  this  direction.  The 
discovery  of  the  remarkable  properties  exercised  on  the  nervous  system 
by  the  inhalation  of  nitrous  oxide,  then  led  Sir  Humphry  Davy  and 
others  to  entertain  hopes  that  it  might  be  used  as  a  means  of  relieving 
pain  during  surgical  operations.  Experiments  w^ere  made  wdtli  the  gas 
with  this  view,  but  they  did  not  prove  altogether  satisfactory,  and  it 
was  abandoned,  except  as  a  means  of  amusement. 

It  is  needless  to  do  more  than  allude  to  such  means  as  the  compression 
of  the  nerves  of  the  limb,  as  recommended  by  Moore — the  employment 
of  excessive  venesection,  as  adopted  by  Wardrop — or  the  production 
of  insensibilit}^  by  mesmerism  by  Esdaile  and  others.  These  means  of 
inducing  anaesthesia  were  either  inefficient,  dangerous,  or  chimerical. 

It  was  not  until  1844  that  a  serious  attempt  was  again  made  to 
introduce  insensibility  during  operations  by  inhalation :  and  to  the 
Americans  is  undoubtedly  due  the  honor  of  having  established  the 
practice  of  Anaesthesia  in  Surgery.  Tn  that  3"ear  Horace  Wells,  a  dentist 
of  Hartford,  Connecticut,  inhaled  the  nitrous  oxide  gas  with  a  view  of 
rendering  himself  insensible  during  the  extraction  of  a  tooth;  and, 
finding  the  experiment  succeed,  repeated  it  on  sever'al  of  Iris  patients. 
Its  success  was  not,  however,  permanent ;  and  having  failed  in  several 
cases,  he  seems  to  have  given  up  the  attempt.  In  1846  Dr.  Morton,  a 
dentist,  and  a  pupil  of  Wells,  used  the  vapor  of  ether  instead  of  the 
rrrtrous  oxide  gas ;  and,  having  succeeded  in  extracting  several  teeth 
painlessly,  applied  to  the  authorities  of  the  Massachusetts  General 
Hospital  at  Boston  for  permission  to  administer  it  to  a  man  from  whom 
Dr.  J.  C.  Warren  was  about  to  remove  a  tumor  of  the  neck.  The  result 
was  most  successful.  The  news  of  this  great  discovery  was  immediately 
sent  to  England,  wher-e  the  first  operations  on  patients  anaesthetized 
by  the  inhalations  of  tire  vapor  of  ether,  were  performed  at  the  Uni¬ 
versity  College  Hospital  by*  Liston,  who  amputated  a  thigh  and  tore 
out  an  ingrowing  toe-nail  without  any  suffering  to  the  patient.  This 
was  on  December  22,  1846 ;  and  from  that  time  the  use  of  anresthetics 


28 


GENEEAL  EEMARKS  ON  OPERATIONS. 


lias  been  established  in  surgical  practice  in  every  civilized  countiy  in 
the  world. 

For  more  than  a  year,  sulphuric  ether  was  the  only  agent  habitually 
used  for  inducing  aniEsthesia.  But  during  the  whole  of  this  period 
maii}^  professional  men  w^ere  busy  with  experiments  on  the  anmsthetic 
influence  of  various  kinds  of  vapors;  and  in  November  1847,  Professor 
Simpson,  of  Edinburgh,  published  an  account  of  the  ansesthetic  pro¬ 
perties  of  chloroform.  In  this  country,  this  agent'  soon  came  to  be 
generally  emplo3’ed,  although  ether  held  its  ground  with  the  American 
surgeons,  b}"  man}'  of  whom  it  is  preferred  to  chloroform  at  the  present 
time. 

The  employment  of  ansesthetics  in  surgery  is  undoubtedly  one  of  the 
greatest  boons  ever  conferred  upon  mankind.  To  the  patient  it  is  in¬ 
valuable  in  preventing  the  occurrence  of  pain,  and  to  the  Surgeon  in 
relieving  him  from  the  distress  of  inflicting  it.  Anaesthesia  is  not, 
however,  an  unmixed  good.  Every  agent  by  which  it  can  be  induced 
produces  a  powerful  impression  on  the  system,  and  may  occasion 
dangerous  consequences  when  too  freely  or  carelessly  given  ;  and  even 
with  every  possible  care,  it  appears  certain  that  the  inhalation  of  any 
anaesthetic  agent  is  in  some  cases  almost  inevitably  fatal.  We  cannot 
purchase  immunity  from  suffering  without  incurring  a  certain  degree  of 
danger.  There  can,  however,  be  little  doubt  tliat  many  of  the  deaths 
that  have  followed  the  inhalation  of  anaesthetics  have  resulted  from 
want  of  knowledge  or  of  due  care  on  the  part  of  the  administrators. 
T'et,  whatever  precautions  be  taken,  there  is  reason  to  fear  that  a  fatal 
result  must  occasionally  happen.  This  immediate  risk,  which  is  but 
very  small,  is  more  than  counterbalanced  by  the  immunity  from  other 
dangers  during  operations  which  used  formerly  to  occur. 

There  is,  however,  another  question  in  relation  to  chloroform  which 
deserves  the  most  serious  consideration  on  the  part  of  the  Surgeon  ;  viz.. 
Does  it  influence  the  rate  of  mortality  after  operations  ?  On  this  point 
there  is  conflicting  testimony.  Simpson  has  published  statistics  to 
show  that  the  mortality  after  operations  has  lessened  since  the  intro¬ 
duction  of  chloroform.  J.  Arnott,  on  the  other  hand,  adduces  figures 
to  prove  that  it  has  materially  increased,  in  amputation  by  12,  in 
lithotomy  by  as  much  as  28  per  cent.  I  am  inclined  to  believe  that  the 
rate  of  mortality  has  increased  since  the  use  of  chloroform  in  operative 
surgery.  But  is  this  increase  altogether  due  to  any  eflfect  produced  on 
the  system  by  the  inhalation  of  chloroform  ?  May  it  not,  in  some 
measure  at  least,  be  owing  to  operations  being  often  performed  in  very 
doubtful  or  extreme  cases,  now  that  they  can  be  done  painlessly,  when 
formerly  the  sulfering  inflicted  would  have  deterred  the  Surgeon  from 
proposing,  or  the  patient  from  acceding  to,  their  performance  ?  A 
surgical  operation  w'as  formerl}^,  from  the  pain  attending  it,  looked  upon 
as  a  more  serious  affair  than  it  is  at  the  present  day,  and  surgeons  were 
not  willing  to  inflict  suflTering  unless  there  were  a  good  prospect  of  a 
successful  issue.  Now,  however,  that  the  most  serious  operations  can 
be  performed  without  any  consciousness  to  suffering,  the  Surgeon,  in  his 
anxiety  to  give  his  patient  a  chance  of  life,  may  not  unfrequently  ope¬ 
rate  for  disease  or  injury  that  would  otherwise  necessarily  and  speedily 
be  fatal,  and  which  formerly  would  have  been  left  w'ithout  an  attempt 
at  relief. 

Making,  however,  all  allowance  for  the  extension  of  operative  siu’gery 
to  extreme  cases  that  were  formerly  not  thought  to  come  within  its 
range,  I  cannot  but  think  that  chloroform  does  exercise  a  noxious 


ADMINISTEATIOX  OF  CHLOEOFORM. 


29 


influence  on  the  constitution,  and  does  lessen  the  prospect  of  recovery 
in  certain  states  of  the  system,  more  especially  when  the  nervous  power 
is  enfeebled  or  the  blood  is  in  an  unhealthy  state.  In  such  circumstances, 
the  depressing  influence  of  chloroform  appears  to  me  to  act  injuriously; 
the  patient  does  not  rally  W’ell  after  the  operation  for  which  it  is  ad¬ 
ministered,  and  immunit}’’  from  suffering  is  purchased  by  a  lessened 
chance  of  recoveiy. 

Anseathesia  by  the  Administration  of  Chloroform  is  best  commenced 
before  the  patient  leaves  his  bed.  The  chloroform  should  never  be  given 
but  by  a  person  accustomed  to  its  use,  and  on  whose  capability  the 
Surgeon  has  full  reliance;  as  nothing  embarrasses  more,  during  an 
operation,  than  to  have  any  doubt  about  the  chloroform  being  properly 
administered.  Chloroform  may  be  administered  in  many  different  ways, 
either  on  lint  or  on  a  handkerchief,  or  througli  an  inhaler  of  some  kind. 
The  following  is  the  way  in  which  chloroform  may  most  safely  be  given 
on  lint  or  a  handkerchief,  without  apparatus  of  any  kind.  On  a  j)iece 
of  folded  lint,  about  two  inches  square,  and  consisting  of  three  doubles, 
about  a  drachm  of  chloroform  is  poured ;  and  the  lint  is  then  held  at  a 
distance  of  about  three  inches  from  the  nose  of  the  patient,  so  as  to 
permit  a  very  free  admixture  of  air  w'ith  the  first  few  inhalations  of  the 
vapor.  After  the  lapse  of  about  half  a  minute,  the  lint  is  brought 
nearer  to  the  patient’s  nose,  to  within  a  distance  of  perhaps  an  inch, 
being  never  allowed  to  touch;  at  the  same  time  a  porous  towel,  not 
doubled,  is  lightly  laid  over  the  face  of  the  patient  and  the  hand  of  the 
operator,  so  as  to  prevent  the  escape  of  the  chloroform-vapor,  but  not 
to  interfere  with  the  admission  of  air.  During  the  whole  time,  it  is  the 
duty  of  the  administrator  to  keep  his  hand  on  the  pulse,  to  watch  the 
breathing,  and  occasionally  to  examine  the  piq^ils  of  the  patient. 

The  method  just  described  (giving  chloroform  on  lint,  the  patient’s 
head  being  covered  wMth  a  towel)  answers  well  enough  in  most  cases,  but 
it  affords  no  means  of  ascertaining  the  proportion  of  chloroform  in  the 
air  which  is  being  inhaled  hy  the  patient.  The  administrator  can  judge 
only  by  the  effects  produced.  There  is  a  danger  of  the  patient’s  lungs 
being  filled  with  a  very  strong  mixture  at  the  moment  when  the  signs 
of  an  overdose  are  first  perceived.  In  the  most  favorable  circumstances 
it  requires  several  respirations  to  replace  the  strong  dose  by  fresh  air; 
but  if  the  patient  happen  to  be  in  a  rigid  state,  or  his  glottis  be  closed 
by  spasm,  considerable  delay  will  occur,  during  which  time,  if  the  dose 
have  not  been  strong  enough  to  arrest  the  action  of  the  heart,  the 
blood  is  passing  through  the  lungs  and  becoming  further  charged  with 
chloroform. 

Various  inhalers  have  been  contrived  for  the  purpose  of  regulating 
the  proportion  of  chloroform  with  accuracy.  The  simplest  kind  con¬ 
sists  of  a  mask  covering  the  nose  and  mouth,  with  a  box  for  sponge  or 
blotting-paper  on  which  the  chloroform  is  poured,  and  with  valves  to 
prevent  the  expired  air  from  passing  through  the  chloroform-chamber. 
The  objection  to  this  form  is,  that  it  yields  a  very  strong  mixture  at 
first ;  and,  when  the  chloroform  has  half  evaporated,  the  remainder  is 
so  cooled  that  it  evaporates  too  slowlj^  to  yield  enough  chloroform  to 
insure  the  quietude  of  the  patient,  especiall3"  if  he  should  move  his  head 
about  so  as  to  get  a  small  quantity  of  air  between  his  face  and  the 
mouthpiece. 

Dr.  Snow  improved  this  apparatus  by  surrounding  the  chloroform 
chamber  with  water,  and  also  making  the  upper  valve  movable,  so  that 
at  the  beginning  of  the  inhalations  only  a  portion  of  the  inspired  air 


80 


GEXEKAL  REMAKES  ON  OPERATIONS. 


should  pass  over  the  chloroform.  This  was  a  great  improvement ;  hut 
accuracy  was  not  secured,  because  the  proportion  of  chloroform  given 

up  varies  with  the  temperature 
of  the  room,  with  the  slowness 
or  rapidity  of  the  patient’s 
breathing,  and  with  the  cooling 
of  the  chloroform,  which  is  not 
entirely  prevented  by  the 
water-jacket. 

Clover  has  devised  an  appa¬ 
ratus,  consisting  of  a  bag  hold¬ 
ing  8000  cubic  inches  of  air, 
which  is  suspended  from  the 
coat  collar  at  the  back  of  the 
administrator,  and  connected 
with  the  face-piece  by  a  flexi¬ 
ble  tube  (Fig.  2).  The  bag  is 
charged  by  means  of  a  bellows 
(Fig.  1,  i)  measuring  1000 
cubic  inches ;  and  the  air  is 
passed  through  a  box  warmed 
with  hot  water,  into  which  is 
introduced,  at  each  filling  of 
the  bellows,  as  much  chloro¬ 
form  as  is  required  for  1000 
cubic  inches  of  air.  This  is 
done  with  a  graduated  glass 
S3’ringe  (Fig.  1,  2)  adjusted  by 
a  screw  on  the  piston-rod  to 
take  up  no  more  than  the  quan¬ 
tity  determined  on,  which  is 
usuall}'  from  30  to  40  mimims. 
When  the  bag  is  full  enough, 
the  tube  is  removed  from  the 
evaporating  vessel,  and  the 
mouthpiece  (Fig.  1,  3)  adapted 
to  it. 

The  patient  cannot  get  a 
stronger  dose  than  the  bag  is 
charged  with;  but  the  pro¬ 
portion  can  be  made  an}’  degree  weaker,  b}’  regulating  the  size  of  an 
opening  in  the  mouthpiece,  which  admits  additional  air. 

The  result  of  Clover’s  experience  with  this  instrument  is  of  the  most 
favorable  character.  He  has  administered  this  anaesthetic  in  more  than 
3000  cases  without  an  accident  of  an}’  kind. 

The  principal  points  to  be  attended  to  during  the  inhalation  of  this 
potent  agent  are,  that  it  be  not  given  too  suddenly,  or  in  too  concentrated 
a  form  ;  and  that,  whilst  under  its  influence,  the  patient  be  not  raised 
into  the  erect  or  sitting  position.  If  lint  be  used,  it  may  be  too  much 
saturated,  and  be  held  too  closely  applied  to  the  mouth  and  nostrils;  and 
the  patient  will  not  be  able  to  get  suflScient  atmospheric  air,  and  may 
speedily  become  partially  asphyxiated,  choking  violently,  struggling  to 
get  free,  and  becoming  purple  in  the  face,  with  a  full  slow  pulse.  Care 
should  be  taken  not  to  compress  the  abdomen  in  holding  the  patient ; 
for,  as  the  respiration  becomes  chiefly  or  wholly  diaphragmatic,  it  may 


Clover’s  Chluroform  Apparatus. 


Fig.  2. 


Administration  of  Chloroform  by  Clover’s  Apparatus. 


CAUTIONS  REGARDING  CHLOROFORM. 


81 


be  seriously  interrupted  b}'  any  pressure  on  the  abdominal  wall.  Whilst 
under  the  influence  of  chloroform,  the  patient  should  never  be  raised  up, 
as  has  just  been  stated  ;  for  as  this  agent  exercises  a  powerful  sedative 
action  on  the  heart,  sudden  and  perhaps  fatal  syncope  may  ensue  from 
putting  the  patient  into  the  erect  position.  Hence,  also,  it  is  dangerous 
to  administer  it  in  those  operations  that  require  to  be  performed  whilst 
the  patient  is  erect.  It  is  well  to  caution  the  patient  not  to  take  any¬ 
thing  to  eat  for  two  or  three  hours  before  its  administration,  lest  it 
induce  vomiting  of  the  partiallj'  digested  meal.  With  due  caution,  it 
may  be  given  with  perfect  safety  to  individuals  of  all  ages.  1  have 
operated  on  infants  less  than  a  week  old,  as  well  as  on  octogenarians, 
under  its  influence.  In  administering  it  to  young  children.  Snow  recom¬ 
mends  its  dilution  with  rectified  spirit. 

The  first  influence  of  chloroform  appears  to  be  exercised  upon  the 
nervous  S3’stem.  The  patient  becomes  excited  and  talkative,  and  a  state 
of  unconsciousness  is  induced,  the  muscular  sj^stem  at  the  same  time 
being  rendered  rigid  and  tense.  At  this  time  the  heart’s  action  is 
usually  quickened,  and  more  forcible  than  natural.  As  the  adminis¬ 
tration  of  the  chloroform  continues,  however,  complete  paralysis  of 
sensation  and  motion  is  induced.  The  patient  becomes  altogether 
unconscious  to  all  external  impressions,  the  muscles  become  relaxed 
and  the  action  of  the  heart  slow  and  feeble.  This  diminution  in  the 
power  of  the  heart’s  action  is  well  marked  in  the  lessened  force  of  the 
jet  of  blood  from  cut  arteries.  The  respirations  become  shallow  and 
feeble,  in  proportion  as  the  sensibility'  of  the  nervous  sy'stem  and  the 
energy'  of  the  muscular  movements  are  lessened,  and  the  blood  in  the 
arteries  becomes  dark;  in  fact,  a  semi-asphyxial  state  sets  in.  When  thus 
fully  anaesthetized,  the  patient  is  undoubtedly^  on  the  very  verge  of  death, 
and  requires  the  most  careful  watching  by  the  person  who  administers 
the  chloroform  ;  his  finger  should  never  be  off  the  pulse,  nor  his  eyes 
taken  away  from  the  countenance  of  the  patient.  The  breathing  should 
be  very  carefully  observed:  when  it  becomes  embarrassed  chloroform  must 
be  given  sparingly^,  and  when  it  becomes  stertorous  it  should  be  discon¬ 
tinued  entirely.  In  this  state,  the  inhalation  of  a  small  additional 
quantity  of  this  potent  agent,  the  application  of  the  vapor  in  too  con¬ 
centrated  a  state,  or  the  sudden  rising  up  of  the  patient,  might  occasion 
death  from  paraly'sis  of  the  heart. 

If  the  inhalation  of  chloroform  have  been  suspended,  great  care 
should  be  taken  when  its  administration  is  recommenced,  lest  the 
already  enfeebled  heart  be  entirely  overpowered  by  the  influence  of  too 
large  a  volume  of  vapor  suddenly  given  in  a  concentrated  form. 

It  should  be  borne  in  mind  that  it  is  not  necessary  in  all  operations  to 
administer  chloroform  to  the  same  extent.  In  all  the  greater  operations, 
as  amputations,  lithotomy',  and  the  ligature  of  arteries,  enough  should 
be  given  to  completely  paralyze  muscular  movement,  as  well  as  to  sus¬ 
pend  sensibility  and  consciousness.  In  operations  for  hernia,  also,  and 
all  other  proceedings  implicating  the  abdominal  walls,  if  complete  mus¬ 
cular  relaxation  be  not  induced,  great  inconvenience  and  not  a  little 
danger  may  result.  Sv),  also,  in  very'  painful  operations  about  the  anus 
and  genital  organs,  a  full  dose  of  chloroform  should  be  given.  But  for 
the  removal  of  many  tumors  about  the  trunk,  or  in  many'  of  the  minor 
operations  on  the  extremities  and  about  the  head  and  face,  muscular 
relaxation  is  not  so  necessary ;  and  it  will  be  sufficient  to  give  enough 
chloroform  merely'  to  suspend  sensibility  and  consciousness  to  pain. 

In  certain  diseased  conditions  of  the  system  the  administration  of  chlo- 


32 


GENERAL  REMARKS  ON  OPERATIONS. 


reform  requires  much  care ;  but.  as  a  general  rule,  it  may  be  stated  that, 
whenever  the  constitutional  disease  has  not  advanced  to  such  a  de<jree 
as  to  contraindicate  an  operation,  chloroform  ma}'  be  given.  In  the  early 
stages  of  phthisis  it  may  usuall}'  be  safelj-  inhaled  ;  but  in  some  cases  of 
bronchial  irritation  the  vapor  is  apt  to  produce  troublesome  cough. 
'When  the  heart  is  diseased,  great  caution  is  necessaiy,  more  particularly 
when  its  muscular  substance  has  undergone  fatty  degeneration ;  the 
sedative  influence  of  the  chloroform  being  apt,  in  these  circumstances,  to 
produce  a  sudden  depression  or  arrest  of  the  heart’s  action.  In  many, 
perhaps  the  majoritj^,  of  the  cases  of  death  from  chloroform,  the  fatal 
event  has  been  traced  to  this  cause.  In  valvular  disease  of  the  heart  I 
believe  that  it  may  be  more  safely  given.  In  persons  who  are  epileptic, 
and  in  those  who  suffer  from  congestion  of  the  brain,  it  requires  to  be 
cautiousl}'  administered,  as  in  the  earlier  stages  of  anaesthesia  much 
cerebral  excitement  is  apt  to  be  evinced.  In  hysterical  subjects,  chlo¬ 
roform  is  said  to  induce  a  tendency  to  laryngeal  spasm.  The  most 
dangerous  condition  in  which  to  administer  chloroform  is  that  in  which, 
in  consequence  of  renal  disease,  the  blood  is  loaded  with  urea ;  in  such 
cases  epileptiform  convulsions  are  readilj^  induced,  with  lividity  of  the 
face,  and  a  tendenc}'  to  stertor  and  coma. 

Should  chloroform  be  given  in  operations  rendered  necessary  by  severe 
injuries^  during  the  period  of  the  continuance  of  the  shock  of  the  acci¬ 
dent,  as  in  primaiy  amputations  ?  In  such  circumstances,  its  use  has 
been  objected  to  on  the  ground  that  it  would  act  injuriously  b}^  still 
further  lowering  the  already  depressed  vital  powers ;  and  that  the  pain 
of  the  operation,  if  performed  without  it,  would  prove  a  good  stimulant, 
and  thus  serve  to  rouse  the  patient.  But  would  this  realh"  be  so  ?  Is 
the  pain  of  an  operation  a  stimulant  ?  In  order  to  answer  this  question, 
let  us  observe  the  condition  of  a  patient  immediately  after  the  perform¬ 
ance  of  a  severe  operation — as  an  amputation — without  his  having  been 
anaesthetized;  and  we  shall  find  that,  so  far  from  having  been  restored 
or  stimulated,  he  will  have  been  seriously  depressed  by  it.  The  pulse 
will  be  small,  feeble,  and  slow;  the  surface  cold  ;  and  the  mind,  perhaps, 
scarcely  conscious :  in  fact,  though  a  slight  degree  of  pain,  as  a  pinch  or 
a  prick,  ma}"  act  as  a  stimulant,  very  severe  suffering  is  a  most  powerful 
depressing  agent,  capable  in  itself  of  destro3ing  life.  The  pain  of  an 
operation  performed  soon  after  the  occurrence  of  a  severe  injury,  so  far 
from  rousing  the  patient,  appears  to  me  to  act  most  injuriousl}',  b^" 
inflicting  a  second  shock  upon  the  s^'stem  before,  perhaps,  it  has  fairly 
recovered  from  the  depressing  effects  of  the  first ;  and  it  is  b^"  preventing 
this  that  chloroform  is  of  such  inestimable  advantao-e.  In  these  cases  it 

o 

is  not  necessaiy  to  give  chloroform  to  an  extreme  degree  of  anresthetiza- 
tion.  It  is  onh"  requisite  to  give  it  to  a  moderate  extent,  chiefly"  so  as 
to  benumb  sensation  during  the  incisions  made  through  the  skin.  After 
this,  and  during  the  later  stages  of  the  operation,  the  inhalation  may  be 
suspended  entireh’,  or  nearly  so.  It  is  an  interesting  ph^’siological  fact, 
that  the  plysical  effect  of  shock  is  produced  on  the  sj’stem  even  though 
the  patient  be  completelv"  anaesthetized.  This  is  particularly^  noticeable 
in  cases  of  castration,  in  which,  at  the  moment  when  the  cord  is  cut,  the 
pulse  will  be  found  to  fall  several  beats  or  to  stop  momentarily,  even 
though  the  patient  be  quite  insensible.  Hence,  it  may^  be  argued  that, 
although  anaesthesia  saves  the  patient  that  amount  of  shock  which  arises 
from  pain,  it  does  not  relieve  him  of  that  which  results  from  the  physical 
impression  produced  on  the  system  by  a  severe  mutilation. 

Secondary  Effects  of  Chloroform  may"  develop  themselves  in  connec- 


MODES  OF  DEATH  FROM  CHLOROFORM. 


33 


tion  with  the  head^  the  luncjs^  or  the  stomach.  The  liabilit}’  to  inconve¬ 
nient  secondary  effects  depends  chiefly  on  two  conditions :  1.  on  the 
mode  of  administration  of  the  chloroform,  especially  on  the  care  taken 
that  there  is  an  adequate  supply  of  air  admitted  at  the  time  when  the 
vapor  is  inhaled  ;  and  2,  on  the  state  of  the  patient  as  to  age,  habit,  tem¬ 
perament,  and  digestion.  Old  people,  habitual  spirit-drinkers,  and  those 
of  a  bilious  and  sanguine  temperament,  are  apt  to  suffer  most.  The 
condition  of  the  digestion  is  of  great  importance.  If  chloroform  be 
given  too  soon  after  a  meal,  injurious  results  are  sure  to  follow,  hence, 
it  is  best  administered  on  an  erapt}-  stomach. 

Head- Complications  chiefly  follow  the  administration  of  chloroform  in 
the  aged.  In  them  headaches  and  stupor  not  unfrequentl}^  supervene, 
and  occasionally  paralytic  or  apoplectic  symptoms  will  develop  them¬ 
selves  some  days  after  the  anaesthesia.  In  j’oung  and  nervous  women 
hysterical  symptoms  often  appear,  and  continue  for  some  hours  or  even 
days ;  but  the}^  need  not  excite  uneasiness. 

The  Lungs  probably  alwa3’s  become  slightl^^  congested  during  the 
administration  of  chloroform.  But,  as  recovery  takes  place,  and  the 
respiratoiy  process  is  naturally  re-established,  the  pulmonary  vessels 
unload  themselves,  and  no  inconvenience  results.  The  process  is  greatl}^ 
facilitated,  and  tlie  effects  of  chloroform  are  readily"  got  rid  of,  by'  desiring 
the  patient  to  breathe  several  times  fully  and  deeply  after  consciousness 
returns.  In  some  cases  the  lungs  do  not  unload  themselves  of  the  accu¬ 
mulated  blood ;  and  a  process  of  slow  asphy^xia  or  a  low  form  of  pneu¬ 
monia  may  set  it,  and  may  prove  fatal  in  a  period  varyung  from  twenty'- 
four  hours  to  four  or  six  day's.  This  is  especially^  apt  to  happen  in  those 
cases  in  which  it  becomes  necessary'  to  bandage  the  chest,  or  in  which 
deep  respiration  is  attended  by'  pain,  as  after  amputation  of  the  breast. 
Great  care  must,  therefore,  be  employ'ed  not  to  adopt  too  much  constric¬ 
tion  of  the  chest-walls  after  such  operations. 

Irritability  of  the  Stomachy  attended  by  continued  nausea  and  vomiting, 
is  sometimes  a  very  distressing  after-consequence  of  chloroform,  and 
may  be  productive  of  most  serious  and  even  of  fatal  results.  In  many' 
instances  it  is  developed  by  the  patient  taking  the  chloroform  too  soon 
after  a  meal,  and  is  then  purely  gastric.  In  other  instances  it  appears  to 
be  sympathetic  with  cerebral  disturbance  of  some  kind ;  in  other 
instances,  again*,  it  is  connected  with  kidney'-disease.  But  in  any*  case, 
and  from  whatever  cause  arising,  it  is  a  very'  serious  syunptom,  and,  if  it 
continue,  often  turns  the  scale  against  the  patient  by  the  exhaustion  to 
which  it  gives  rise.  It  is  best  treated  by  ice  and  opium. 

Death  from  Chloroform  may  occur  in  three  different  ways;  viz.,  by^ 
Coma^  by  Asphyxia.^  or  by  Syncope ;  through  the  brain,  the  lungs,  or 
the  heart. 

When  death  occurs  by  Coma,  the  patient  is  heard  suddenly'  to  breathe 
stertorously  ;  he  becomes  livid  in  the  face,  and  is  convulsed ;  the  heart 
beats  until  the  last  moment  of  life,  and  death  appears  to  result  pri¬ 
marily  from  the  circulation  of  dark  blood  through  the  nervous  centres. 
This  form  of  death  chiefly  occurs  in  individuals  who  are  epileptics,  or 
whose  blood  is  loaded  with  urea. 

Death  by^  Asphyxia  may  be  produced  in  one  of  two  way's.  I.  It  may' 
be  the  fault  of  the  administrator,  suflScient  air  not  being  admitted  with 
the  chloroform-vapor  to  maintain  the  respiratory^  function.  This  is  espe¬ 
cially  apt  to  happen  when  a  patient,  being  semi-narcotized,  has  a  piece  of 
lint  saturated  with  chloroform  suddenly'  applied  to  the  mouth  and  nose, 
the  heat  of  the  operator’s  hand  and  of  the  patient’s  body  rapidly  raising 
VOL.  I. — 3 


84 


GENERAL  REMARKS  ON  OPERATIONS. 


a  large  volume  of  vapor.  2.  Lister  described  the  production  of  asph^^xia 
as  being  due  to  spasmodic  closure  of  the  upper  opening  of  the  larynx, 
the  folds  of  mucous  membrane  above  the  apices  of  the  aiytaenoid  carti¬ 
lages  being  carried  forwards  till  the}’  are  in  contact  with  the  base  of  the 
epiglottis,  which  remains  erect  and  unchanged  in  position.  This  theory 
was  founded  on  observations  of  the  larynx  during  the  production  of 
that  peculiar  laiyngeal  stertor  which  usually  precedes  the  stoppage  of 
the  respiration.  On  pulling  the  tongue  forcibly  forward,  the  arytasnoid 
cartilages  were  seen  to  be  drawn  backward,  and  the  opening  of  the 
larynx  made  perfectly  free  again ;  and  this  seems  to  be  due  to  reflex 
action  and  not  to  mechanical  causes.  This  is  quite  possible  during 
anaesthesia,  as  the  reflex  functions  of  deglutition  and  respiration  are  not 
affected  by  chloroform  as  administered  for  a  surgical  operation.  This 
state  of  things  maj^  often  pass  unnoticed  till  the  pulse  stops,  as  the 
heaving  of  the  chest  may  go  on  for  some  time  after  an}’  air  has  ceased 
to  enter ;  the  only  signs  of  the  state  of  the  patient  being  the  gradually 
increasing  lividity  of  the  face,  and  the  fact  that  no  air  is  entering  or 
coming  out  during  respiration,  which  can  be  ascertained  by  feeling  with 
the  hand  over  the  mouth.  Lister  is  of  opinion  that  many  of  the  deaths 
from  chloroform,  in  which  the  heart  has  been  said  to  stop  first,  were 
cases  of  this  kind. 

In  death  from  Cardiac  Syncope^  the  patient,  after  a  few  inspirations, 
suddenl}’  becomes  pale  and  faint;  the  pulse  beats  in  a  flickering  manner 
a  few  times  and  then  ceases,  though  respiration  ma}’  continue:  the  fatal 
event  being  evidently  due  to  paral3^sis  of  the  heart.  This  is  an  accident 
that  may  occur  to  individuals  who  are  depressed  either  by  mental 
emotion  or  by  physical  debility  before  taking  the  chloroform  ;  and  it  is 
not  unfrequently  connected  with  a  fatty  heart.  It  is  best  guarded 
against  b}’^  giving  the  patient  a  little  stimulant,  as  brandy  or  ammonia, 
before  commencing  the  inhalation. 

Lister’s  rules  for  the  administration  of  chloroform  are  to  watch  the 
respiration  in  preference  to  the  pulse ;  to  cease  administration  at  once 
when  the  peculiar  lar3mgeal  stertor  is  produced ;  and  if  this  pass  on  to 
complete  obstruction  of  respiration,  to  pull  the  iovignQ  forcibly  forwards 
so  as  to  cause  retraction  of  the  aiytsenoid  cartilages  b}’  refiex  action, 
and  not  merel}'  to  bring  the  tip  just  in  front  of  the  teeth  as  is  usually 
done,  under  the  impression  that  the  obstruction  is  due  to  the  falling 
back  of  the  tongue. 

The  Adminintration  of  Ether  is  eftected  by  the  application  over  the 
nostrils  of  a  hollow  sponge  saturated  by  the  best  washed  ether.  This 
mode  is  preferable  to  the  use  of  an}^  of  the  complicated  inhalers  ;  inas¬ 
much  as,  by  the  admixture  in  the  sponge  of  a  sufficient  quantity  of 
atmospheric  air  with  the  ethereal  vapor,  all  danger  of  asph3’xia  is 
avoided.  To  prevent  the  pungent  effects  of  ether  on  the  cutaneous  sur¬ 
face,  Dr.  Warren  has  proposed  the  anointing  of  the  face  with  some  pro¬ 
tective  unguent.  The  first  effects  of  the  inhalation  are  resistance  on  the 
part  of  the  patient,  and  some  slight  irritation  of  the  air-passages ;  the 
pulse  is  increased  in  rapidity,  rising  to  one  hundred  pulsations  per 
minute ;  the  face  becomes  fiushed,  and  the  movements  and  speech  of  the 
patient  excited.  This  stage  of  excitement  soon  passes,  and  full  etheri¬ 
zation  is  then  effected ;  the  pulse  falls  to  sixty  or  seventy,  the  counte¬ 
nance  becomes  pale,  insensibilit}'’  to  pain  is  produced,  and  the  whole 
muscular  S3’stem  is  relaxed.  The  indications  of  this  state  are  the  dropping 
of  the  upper  e3’elid,  and  the  inabilit}’’  of  the  patient  to  sustain  his  arm 
when  raised.  This  is  the  period  most  favorable  to  the  performance  of 


BICHLORIDE  OF  METHYLENE. 


35 


operations  and  especiall}’’  for  the  reduction  of  dislocations  and  of  frac¬ 
tures  attended  with  shortening  of  the  limb.  The  time  required  for  the 
induction  of  the  anaesthetic  state  varies  ;  averaging,  perhaps,  about  five 
minutes,  a  longer  time  than  is  required  in  the  administration  of  chloro¬ 
form,  and  attended  with  slightl}’  more  excitement.  The  fatal  consequences 
which  have  attended  the  emplo3^ment  of  chloroform  have  caused  the 
American  surgeons  almost  entireh^  to  trust  to  ether  in  preference. 
Ether  is  certainl}-"  a  safer  agent  than  chloroform,  but  few  deaths  having 
resulted  from  its  administration;  and  the  onl}'’  argument  in  favor  of  the 
use  of  chloroform  rather  than  ether  is,  that  chloroform  is  the  most  con¬ 
venient  agent,  its  effects  being  produced  more  quick!}’,  and  no  disa¬ 
greeable  smell  being  left,  as  is  the  case  with  ether. 

Nitrous  Oxide  Gas  was  a  few  years  ago  introduced  as  an  anaesthetic 
by  American  practitioners.  It  is  undoubtedly  capable  of  producing 
insensibility  to  suffering;  but  as,  owing  to  the  asphyxial  condition  which 
it  induces  when  administered  in  a  pure  state,  its  inhalation  cannot  be 
continued  with  safety  beyond  a  very  few  minutes,  it  only  appears  to  be 
applicable  to  those  cases  in  which  the  operation  is  of  short  duration, 
such  as  the  extraction  of  teeth.  The  anaesthetic  effects  of  this  agent 
completely  pass  off  almost  as  soon  as  the  patient  ceases  to  inspire  it ; 
hence  it  is  not  very  applicable  to  cutting  operations,  in  which  the  after- 
smarting  is  as  much  complained  of  as  the  actual  sting  of  the  cut.  Upon 
the  whole,  it  is  far  inferior  to  ether  or  chloroform  as  an  anaesthetic  in 
all  ordinary  surgical  cases. 

Bichloride  of  Methylene^  originally  suggested  as  an  anaesthetic  by  Dr. 
Richardson,  has  lately  been  extensively  used,  especially  at  Guy’s  Hos¬ 
pital  and  at  the  Moorfields  Ophthalmic  Hospital.  Its  advantages  over 
chloroform  are  said  to  be  greater  rapidity  of  action,  complete  and  rapid 
recovery,  and  the  absence  of  muscular  rigidity  during  administration 
and  of  unpleasant  after-symptoms.  Over  nitrous  oxide  it  has  the 
advantage,  that  the  anaesthesia  can  be  maintained  for  any  length  of  time. 
Though  said  to  be  safer  than  chloroform,  its  use  is  not  perfectly  free  from 
danger,  more  than  one  fatal  case  having  already  occurred ;  and  if  used 
for  operations  lasting  more  than  two  minutes,  it  seems  quite  as  liable  to 
cause  vomiting.  To  produce  rapid  anaesthesia,  it  is  necessary  that  the 
vapor  be  inhaled  in  as  concentrated  a  state  as  possible,  all  unnecessary 
admission  of  air  being  avoided.  For  this  purpose  an  apparatus  has 
been  devised  by  Mr.  Rendle,  of  Guy’s  Hospital,  consisting  of  a  leather 
cylinder,  open  at  one  end  and  shaped  so  as  to  fit  closely  over  the  mouth 
and  nose,  the  other  end  being  dome  shaped  and  perforated  so  as  to 
admit  sufficient  air  for  respiration.  In  the  interior  of  this  cylinder  is  a 
loosely  fitting  flannel  bag,  which  overlaps  the  open  end  and  is  secured 
by  an  elastic  band.  The  administration  is  performed  as  follows.  One 
drachm  of  the  bichloride  of  methylene  is  sprinkled  on  the  inside  of  the 
flannel  bag,  and  the  leather  cylinder  is  immediately  placed  over  the  face 
of  the  patient;  at  first  it  must  not  fit  accurately  to  the  nose  and  mouth, 
but,  as  soon  as  the  patient  can  bear  it,  it  must  be  pressed  firmly  down  so 
as  to  exclude  all  air,  except  such  as  j^asses  through  the  bag.  By  these 
means  anaesthesia  sufficient  for  opening  an  abscess  is  usually  produced 
under  one  minute,  passing  off  as  rapidly  as  it  was  induced.  If  the 
administration  be  prolonged  until  the  drachm  of  the  bichloride  is  com¬ 
pletely  exhausted,  the  anaesthesia  usually  lasts  about  five  minutes  ;  the 
patient  on  recovering  being  able  to  walk  away  with  only  a  slight  feeling 
of  giddiness.  If  necessary  a  second  drachm  may  be  used  to  prolong 
the  effect ;  but  the  after-symptoms  then  resemble  those  of  chloroform, 


36 


GENEKAL  REMARKS  ON  OPERATIONS. 


though  in  a  somewliat  minor  degree.  The  signs  of  danger  during 
administration  are  lividiU"  of  the  face,  and  cessation  of  the  pulse  and 
respiration.  If  they  occur,  it  is  best,  according  to  Dr.  Bader’s  advice, 
to  place  the  patient  at  once  in  the  recumbent  position  on  the  left  side, 
with  the  tongue  well  pulled  forward,  when  the  symptoms  will  gradually 
pass  olf.  Dr.  Richardson  has  concluded  from  experiments  on  animals, 
that  in  fatal  cases  respiration  and  the  heart’s  action  cease  at  the  same 
time.  In  hospital  practice,  where  time  is  of  considerable  importance,  it 
has  been  found  to  be  a  convenient  plan  to  induce  anmsthesia  in  the  first 
instance  by  means  of  bichloride  of  methylene,  and  to  maintain  it  after¬ 
wards  as  long  as  may  be  necessary  by  chloroform. 

The  Treatment  of  the  Effects  arising  from  an  Overdose  of  Anaesthetics 
is  conducted  on  two  principles ;  1,  the  establishment  of  respiration,  either 
natural  or  artificial,  so  as  to  empty  the  lungs  of  the  vapor  contained  in 
the  air-cells,  and  to  aid  the  oxygenation  of  the  blood ;  and  2,  the  stimu¬ 
lation  of  the  heart’s  action,  and  the  maintenance  of  the  circulation. 

The  first  principle  of  treatment — that  of  re-establishing  respiration — 
is  most  serviceable  in  the  asphyxial  form  ;  the  other — that  of  stimulating 
the  heart — when  the  syncopal  symptoms  are  present.  But  in  all  cases 
they  may  most  advantageously  be  emplo3’ed  in  combination. 

The  treatment  to  be  adopted  on  the  occurrence  of  dangerous  symptoms, 
or  of  apparent  death  from  (chloroform,  is  as  follows ; — 

1.  The  administration  of  the  vapor  must  be  at  once  discontinued. 

2.  The  tongue  should  be  seized  with  the  fingers,  or  with  a  hook  or 
forceps,  and  drawn  out  of  the  mouth ;  and  the  larynx  pushed  up  so  that 
the  glottis  may  be  opened. 

3.  Fresh  air  should  be  admitted  to  the  patient  by  opening  doors  and 
windows,  and  by  preventing  bystanders  or  spectators  from  crowding 
round. 

4.  All  constrictions  should  be  removed  from  the  patient’s  throat  and 
chest,  and  tliese  parts  should  be  freely  exposed. 

5.  Artificial  respiration  must  at  once  and  without  delay  be  set  up, 
whilst  these  other  measures  are  being  carried  out,  either  by  the  Surgeon 
applying  his  mouth  to  the  patient’s  lips,  and  thus  breathing  into  the  chest ; 
or,  what  is  preferable,  by  the  alternate  and  steady  compression  and  relaxa¬ 
tion  of  the  walls  of  the  patient’s  chest. 

6.  Electricity  may  be  applied  freely  over  the  heart  and  diaphragm 
through  to  the  spine,  by  means  of  the  electro-magnetic  or  other  conve¬ 
nient  apparatus. 

7.  As  accessory  means,  friction  of  the  extremities  may  be  employed  ; 
a  little  brand}’’  rubbed  inside  the  mouth ;  and  cold  water  dashed  on  the 
face. 

Local  Anaesthesia  may  be  induced  by  freezing  a  part.  This  is  done  in 
two  ways:  I,  by  the  application  of  a  freezing  mixture;  2,  by  the  rapid 
evaporation  of  very  pure  ether.  The  application  of  a  frigorific  mixture 
of  ice  and  snow,  as  introduced  by  Dr.  J.  Arnott,  may  very  conveniently 
be  employed  in  many  cases  in  which  the  internal  administration  of  anaes¬ 
thetics  is  either  inadmissible  or  inconvenient.  It  can  only  be  produced 
with  certainty,  however,  in  those  cases  in  which  the  incisions  merely 
implicate  the  skin  and  subcutaneous  structures,  as  in  opening  abscesses, 
slitting  up  sinuses,  avulsion  of  toe-nails,  or  removing  small  and  super¬ 
ficial  tumors.  For  all  such  purposes,  however,  it  is  extremely  valuable. 

The  mode  of  using  the  frigorific  mixture  is  as  follows.  About  a  tum¬ 
blerful  of  rough  ice  is  put  into  a  strong  canvas  bag,  and  finely  powdered 
with  a  mallet.  It  is  then  poured  out  on  a  sheet  of  paper,  and  half  its 


PERFORMANCE  OF  AN  OPERATION. 


37 


bulk  of  salt  is  quickl}^  mixed  with  it  by  means  of  an  ivory  or  wooden 
paper-knife.  The  mixture  is  then  put  into  a  muslin  or  gauze  bag,  sus¬ 
pended  from  a  w’ooden  ring,  and  applied  to  the  part  for  from  five  to 
ten  minutes.  So  soon  as  the  skin  becomes  white,  opaque,  and  hard, 
anesthesia  is  produced,  and  the  incisions  may  be  made  without  any 
pain  being  experienced.  The  frozen  part  speedily  recovers  itself,  no 
inconvenience  resulting. 

The  rapid  evaporation  of  highly  rectified  ether  has  been  very  inge¬ 
niously  and  successfully  applied  by  Dr.  Richardson  in  the  production  of 
cold  sufficient  to  freeze  a  part,  and  thus  render  it  temporarily  insensible. 
A  fine  spra3^-jet  of  ether  of  a  low  specific  gravity  is  thrown  upon  the 
part  to  be  anaesthetized.  The  skin  rapidly  becomes  white  and  hard — is, 
in  fact,  frozen.  This  method  of  inducing  local  insensibility  to  pain  is 
more  exact  and  efficacious  than  that  b}^  the  frigorific  mixture,  and  is 
generall}’  preferred.  It  is  applicable  in  the  same  class  of  cases. 

Performance  of  an  Operation. — The  Inci^iions  for  the  operation 
itself  should  be  carefull^^  and  properly  planned,  so  as  to  give  sufficient 
space  with  as  little  mutilation  as  possible;  and  in  some  cases  they  must 
be  arranged  with  the  view  of  subsequent  extension,  should  the  state  of 
things  to  be  discovered  require  it.  They  should  be  made  freel}'',  without 
tailing ;  the  point  of  the  knife  being  entered  and  withdrawn  perpendicu- 
larl}^,  and  made  to  cut  with  a  rapid  sawing  motion,  due  attention  being 
at  the  same  time  paid  to  the  resistance  of  the  tissues,  so  that  the  Surgeon 
may  not,  b}"  using  too  much  force,  plunge  or  jerk  his  scalpel  or  bistoury 
into  the  part.  The  scalpel  should  be  set  on  a  smooth  ebon}-"  handle,  which 
is  less  slippery  than  an  ivory  one  when  wetted  with  blood,  and  admits 
greater  delicacy  of  touch ;  it  should  be  light  in  the  blade,  nearly 
straight-backed,  and  slightly  bellied  on  the  cutting  edge.  When  very 
free  and  extensive  incisions  are  required,  as  in  the  removal  of  large 
tumors,  etc.,  Liston’s  spring-backed  bistoury,  of  proper  size  and  shape, 
is  a  most  convenient  instrument.  Whilst  the  incisions  are  being  made, 
care  must  be  taken  that  too  much  blood  is  not  lost.  This  may  be  pre¬ 
vented  most  conveniently  by  the  use  of  the  tourniquet,  or  by  an  assistant 
compressing  the  main  ai’tery  of  the  limb.  If  the  seat  of  the  operation 
be  such  as  not  to  admit  of  this,  the  assistant  must  compress  the  bleeding 
vessels,  as  they  are  divided  during  the  operation;  and  as  soon  as  it  is 
concluded  he  must  remove  his  fingers  from  them,  one  by  one,  to  admit 
of  their  being  ligatured,  or  the  hemorrhage  arrested  by  acupressure.  If 
oozing  continue  after  all  jetting  vessels  have  been  tied,  it  may  be  arrested 
by  exposure  to  the  air,  or  by  pouring  a  stream  of  cold  water  upon  the 
wound.  In  some  cases  the  pressure  of  a  pad  and  bandage,  and  in  others 
that  of  a  sand-bag,  will  arrest  this  bleeding ;  but  in  the  majority  of 
instances  position  and  coaptation  of  the  fiaps  will  suffice. 

The  Sutures  should  be  introduced  at  the  time  of  the  operation,  whilst 
the  patient  is  under  chloroform.  If  the  wound  be  dressed  at  once  they 
are  tied  in  the  usual  way,  and  the  edges  thus  brought  neatly  together. 
If  the  dressing  of  the  wound  be  deferred  foi\a  few  hours,  they  should  be 
left  to  hang  loose,  and  not  be  drawn  tight  until  the  wound  is  dressed. 
In  this  way  the  patient  is  saved  the  pain,  which  is  always  much  complained 
of,  of  introducing  the  sutures  at  the  time  of  the  dressing.  They  are 
generally  best  made  of  dentist’s  twist,  of  moderate  thickness,  so  as  not 
to  cut  out  readily.  Silver  or  unoxydizable  iron  wire  forms  an  excellent 
material  for  sutures  in  the  plastic  operations,  and  in  many  other  cases 
in  which  the  silk  thread  is  apt  to  irritate.  In  some  cases  where  much 


38 


GENERAL  REMARKS  ON  OPERATIONS. 


tension  is  exercised,  or  great  accurac}’  is  required,  harelip  pins  are  pre¬ 
ferable  to  ordinary  sutures. 

Dressing  of  the  Wound. — When  the  wound  is  small,  and  all  oozing  has 
ceased,  its  lips  may  at  once  be  brought  together.  This  ma}"  also  be  done, 
even  when  it  is  large,  if  the  patient  be  of  a  very  irritable  constitution 
and  sensitive  to  pain;  the  whole  dressing  being  performed  whilst  he  is 
still  under  the  influence  of  chloroform.  But  in  general,  when  the  wound 
is  extensive,  as  in  cases  of  amputation,  I  prefer,  and  almost  invariably 
adopt,  the  plan  recommended  b}"  Liston,  of  leaving  the  wound  open  with 
a  piece  of  wet  lint  interposed  between  its  lips,  for  two  or  three  hours, 
until  its  surface  has  become  glazed ;  the  lint  is  then  carefully  removed, 
au}^  small  coagula  are  gently  taken  away,  and  the  sides  of  the  incision 
brought  into  apposition,  the  sutures  being  drawn  tight  and  tied.  Long 
strips  of  plaster  of  moderate  width  should  now  be  applied ;  these  may 
be  either  of  the  isinglass  or  the  common  adhesive  kind,  each  having  ad¬ 
vantages  that  recommend  it  in  particular  cases,  with  corresponding  dis¬ 
advantages  that  exclude  it  in  others.  The  isinglass  plaster  is  clean, 
unirritating,  and,  being  transparent,  allows  a  good  view  of  subjacent 
parts ;  but  it  has  the  disadvantage  of  loosening  and  stripping  olf  when 
moistened  by  the  discharges  or  dressings,  which  often  renders  it  a  very 
inefficient  support.  The  common  adhesive  plaster  is  more  irritating 
and  dirty,  but  it  is  much  stronger,  and  holds  tighter,  not  loosening  so 
readily  when  moistened.  In  large  wounds,  as  in  those  of  amputation, 
I  prefer  the  isinglass  for  the  first  dressing,  and  leave  it  on  until  loosened 
b}'’  the  discharges,  and  then  use  the  common  adhesive  plaster  for  sub¬ 
sequent  applications,  when  less  irritation  is  likel}”  to  be  induced.  In 
some  cases,  in  which  the  wound  is  in  such  a  situation  as  to  admit  of  it, 
and  more  particularly  if  it  be  a  deep  though  clean  cut — as  after  the 
extirpation  of  tumors — great  advantage  will  be  found  after  the  sutures 
have  been  introduced  and  the  plasters  applied,  in  padding  the  part 
externally  with  a  firm  compress  of  diy  lint,  and  then  applying  a  roller 
tightly  but  evenly  over  all,  so  as  to  compress  the  sides  against  the 
bottom  of  the  wound  and  the  edges  firmly  one  against  the  other.  In 
this  way  will  not  onl}"  all  oozing  be  prevented,  but  direct  coalescence 
and  union  of  the  opposed  surfaces  may  be  secured.  This  dry  compress 
may  be  left  undisturbed  for  forty-eight  hours,  when  it  should  be  removed 
and  another  applied,  or,  if  it  appear  more  desirable,  the  part  covered 
with  water-dressing. 

The  position  of  the  part  should  be  carefullj"  attended  to,  so  that  the 
edges  and  surfaces  of  the  incision  be  brought  into  proper  contact ;  more 
may  be  done  in  this  wa3%  without  pain  or  uneasiness  to  the  patient, 
than  b}"  an^'  amount  of  traction  and  pressure  that  can  be  exercised. 
The  part  should  be  so  arranged  that  one  end  of  the  incision  ma^^  be  the 
more  dependent,  so  as  to  facilitate  the  escape  of  discharges.  One  end 
of  each  ligature  should  be  cut  off  short,  the  other  being  left  of  a  moderate 
length  to  hang  out  of  the  lowest  part  of  the  wound,  provided  that  the 
thread  do  not  lie  along  its  whole  line.  A  narrow  strip  of  water-dressing 
should  then  be  applied  along  the  edge  of  the  incision.  The  first  dress¬ 
ings  need  not  be  changed  until  about  the  third  day  after  the  operation, 
unless  they  become  loose  or  have  been  too  tightl}^  applied,  when  they 
may  be  snipped  across.  About  this  time,  or  earlier  in  man}'  cases,  a 
serous  blood}^  fluid  will  be  discharged  from  between  the  strips  of  plaster 
and  the  sutures.  The  escape  of  this  must  be  facilitated  by  removing 
any  obstacles  that  are  in  its  way.  If,  however,  the  sutures  do  not  inter¬ 
fere  with  the  escape  of  the  discharges,  and  do  not  produce  undue  irrita- 


HYGIENIC  TREATMENT. 


39 


§ 

tion  or  excessive  traction,  they  may  be  left  in  for  a  few  days  longer.  In 
amputations,  especially  in  cachectic  subjects,  they  may  frequently  be 
left  undisturbed  for  six  or  eight  days,  with  much  advantage. 

If  union  do  not  take  place  by  adhesive  inflammation,  and  suppuration 
have  commenced,  with  much  tension  and  heat  about  the  part,  the  substi¬ 
tution  of  a  poultice  for  the  water-dressing  will  be  advantageous.  When 
suppuration  has  fairl^^  set  in,  the  applications  should  be  changed  at  least 
twice  or  thrice  in  the  twenty-four  hours.  The  neglect  of  this  precaution 
often  gives  rise  to  much  irritation,  and  retards  the  healing  process  by 
the  accumulation  of  discharges  in  and  around  the  wound.  Care  should 
also  be  taken  that  there  is  a  free  escape  for  the  pus,  which  may  some¬ 
times  be  pent  up  by  the  too  early  cohesion  of  the  edges,  without  a 
corresponding  agglutination  of  the  deeper  surfaces  of  the  wound.  As 
granulations  spring  up,  it  may  become  necessary  to  substitute  astringent 
dressings  for  the  emollient  ones;  and  the  parts  must  be  well  supported 
by  bandages,  especially  in  amputations,  and  in  all  cases  where  there  is 
a  tendency  to  bagging  of  matter. 

The  Constitutional  After-treatment  of  operations  demands  as  much 
attention  on  the  part  of  the  Surgeon  as  the  management  of  the  wound 
itself.  Immediately  after  the  operation,  and  before  the  effects  of  the 
chloroform  have  passed  off,  the  patient  should  be  comfortably  arranged 
in  bed,  with  the  clothes  supported  by  a  cradle,  or  other  contrivance, 
awa}^  from  the  part  implicated ;  an  opiate  should  then  be  administered, 
or  a  little  wine  and  water  if  there  be  faintness,  and  the  patient  kept  as 
quiet  as  possible. 

With  regard  to  the  Diet  after  the  operation^  this  must  depend  entirely 
on  the  patient’s  constitutional  powers,  his  previous  habits,  his  age,  and 
upon  the  severity  of  the  operation.  But,  as  a  general  rule,  it  may  be 
stated  that,  as  an  operation  is  a  shock  to  the  s3’stem,  tlie  constitutional 
powers  usually  require  to  be  maintained  after  its  performance.  This  is 
more  particularly  the  case,  if  the  mutilation  be  severe,  or  the  subsequent 
suppuration  abundant.  If  the  patient’s  strength  be  good,  not  having 
been  broken  b}^  previous  disease  or  suffering,  and  if  the  operation  be  a 
slight  one,  as  the  amputation  of  a  finger,  or  the  removal  of  a  small 
tumor,  he  may  have  half  his  usual  diet  allowed  for  a  few  da^’S,  but 
without  any  stimulants.  If  the  operation  have  been  more  severe,  but 
not  capital,  no  solids  should  be  allowed,  but  broths  and  nourishing 
liquids  alone  given  for  the  first  few  da_ys.  If  the  operation  have  been 
a  capital  one,  the  patient’s  health  and  strength  being  otherwise  good,  he 
may  be  restricted  to  farinaceous  slops  and  beef-tea  until  suppuration  has 
come  on  ;  indeed,  up  to  this  time,  the  febrile  reaction  will  usually"  prevent 
the  patient  from  taking  solids.  Some  light  pudding  may  then  be  added  ; 
and  the  diet  may,  as  the  case  progresses,  be  gradually’  improved  by  the 
successive  addition  of  fish  and  the  lighter  kinds  of  meat,  with  a  moderate 
quantit}''  of  stimulants,  as  required,  until  it  reach  the  normal  standard. 
It  not  unfrequently  happens,  however,  that  a  totally  different  course 
must  be  pursued.  If  the  patient  have  been  much  reduced  by  a  long 
continued  suppuration,  or  other  depressing  causes  before  the  operation; 
if  he  be  old  and  weakly  in  constitution,  or  have  been  in  the  habit  of 
taking  a  veiy  considerable  quantity  of  stimulants,  it  will  be  absolutely 
necessary  to  depart  from  the  routine  plan,  and  to  adopt  a  tonic  and 
stimulating  mode  of  treatment.  Indeed,  in  hospital  practice  especially, 

I  find  this  hy  far  the  most  successful  mode  of  treating  patients  after 
severe  operations;  without  it,  many  would  have  sunk,  whom  I  have 
seen  saved  by  the  free  administration  of  large  quantities  of  brandy,  wine, 


40 


AMPUTATIONS. 


porter,  eggs,  and  beef-tea  from  the  very  time  of  the  operation  ;  that 
stimulant  being  given  to  which  the  patient  is  accustomed  in  a  state  of 
health.  I  believe  also  that  this  plan  of  treatment  is  the  best  preventive 
of  those  low  and  diffuse  forms  of  inflammation  that  are  so  commonly 
fatal  in  these  cases  ;  and  when  they  come  on,  I  know  no  better  remedy 
than  the  brandy-and-egg  mixture,  freely  administered.  In  all  this,  how¬ 
ever,  the  Surgeon  must  be  guided  by  the  patient’s  pulse,  his  previous 
habits,  and  the  power  of  his  constitution  ;  and  nothing  requires  greater 
judgment  than  the  administration  of  stimulants,  according  to  these 
particulars.  The  great  importance  of  attending  scrupulously  to  the 
general  cleanliness  of  the  patient,  and  to  the  ventilation  of  the  ward  or 
room  in  which  he  is  l3dng,  as  the  best  means  of  preventing  the  occur¬ 
rence  of  the  lower  forms  of  inflammatory  mischief,  need  scarcely  be 
insisted  on,  as  these  h3’gienic  precautions  are  universally  recognized  as 
being  of  the  first  importance  under  such  circumstances. 

The  various  Special  Operations  will  be  considered  when  treating  of  the 
several  Injuries  and  Diseases  for  which  the3"  are  required;  but,  as  Am¬ 
putations  do  not  readil3^  fall  under  an3"  special  head,  being  required  for 
a  vast  variety  of  difierent  conditions,  it  will  be  more  convenient  to 
consider  them  here. 


CHAPTER  II. 

AMPUTATIONS  AND  DISARTICULATIONS. 

The  term  Amputation  means  the  separation  or  removal  of  a  part  of  the 
bod3\  It  is  most  commonl3"  applied  to  the  removal  of  a  limb,  but  some¬ 
times  also  to  that  of  other  parts,  as  the  breast  or  penis. 

The  frequenc3'^  of  amputation  of  the  limbs  has  much  lessened  of  late 
3'ears  ;  other  and  less  severe  modes  of  treatment  being  now  successfully 
followed  in  man3"  cases  of  diseased  joint,  of  aneurism,  and  of  compound 
fracture.  Still  amputations  are  among  the  most  frequent  operations  in 
surgeiy,  and  will  continue  to  be  so  as  long  as  the  human  body  is  liable 
to  severe  mutilations,  to  gangrene  of  the  limbs,  and  to  malignant  and 
other  incurable  diseases  of  the  bones  and  joints.  It  has  been  somewhat 
the  fashion  to  decry  amputation ;  and  to  speak  of  this  operation  as  an 
opprobrium  to  curative  surgeiy.  But,  though  no  Surgeon  can  deprecate 
unnecessaiy  amputations  more  strongly  than  I  do,  3'et  I  cannot  admit 
that  the  removal  of  a  limb  is  an  operation  of  less  merit  than  ain^  other 
proceeding  attempted  when  all  other  means  have  failed  in  curing  the 
diseased  part,  or  in  saving  the  patient’s  life  from  danger.  And,  surel3^, 
it  is  rather  a  subject  of  just  pride  than  the  reverse,  for  the  Surgeon  to  be 
able  to  save  the  whole  of  the  body  by  sacrificing  with  ease,  and  b3"  a 
simple  operation,  a  limb  that  has  been  utterly  and  incurablv'  disorganized 
or  spoilt  1)3'  disease  or  injuiy.  In  the  performance  of  an  amputation, 
also,  much  dexterit3'  ma3'  frequently  be  displa3’ed ;  and  there  is  com- 
monl3'  great  scope  for  surgical  skill  in  the  constitutional  treatment  of  the 
patient  both  before  and  after  the  operation. 

The  amputation  of  a  limb  is  generally  performed  in  the  continuity  of 
a  bone;  when  done  at  a  joint,  it  is  called  a  Disarticulation. 

Hemorrhage  during  the  operation  is  the  great  primaiy  danger  which 


AMPUTATION'S. 


41 


must  be  carefully  guarded  against.  As  a  general  rule,  it  is  better  to 
prevent  this  by  the  application  of  a  tourniquet  than  b}"  trusting  to  the 
compression  of  the  artery  b}^  an  assistant’s  fingers ;  the  tourniquet 
arrests  the  flow  of  blood  through  the  collateral  vessels  as  well  as  through 
the  main  trunk,  whilst  the  finger  can  onl}^  stop  the  current  of  blood  that 
passes  through  the  latter.  When  the  tourniquet  is  applied,  the  pad 
should  be  carefully  placed  over  the  artery,  and  the  band  buckled  rather 
tight ;  but  the  instrument  should  not  be  screwed  up  until  the  moment  of 
the  operation.  It  should  then  be  tightened  rapidly,  so  as  to  lessen  the 
liability  to  congestion  of  the  lower  part  of  the  limb  that  always  occurs 
when  a  tourniquet  is  applied,  but  which  is  especially  apt  to  ensue  when 
the  instrument  is  slowly  screwed  up.  The  first  effect  of  the  tightening 
of  the  tourniquet  is  to  compress  the  large  veins  of  the  limb  ;  the  second, 
to  arrest  the  flow  of  blood  through  the  arteries:  hence  the  more  slowly 
it  is  caused  to  act,  the  greater  will  be  the  venous  engorgement  of  the 
limb.  The  blood  that  flows  from  the  limb  during  an  amputation  is  almost 
entirely  venous,  from  the  lower  part  of  the  member.  In  those  cases,  as 
of  chronic  disease,  in  which  it  is  of  great  importance  to  save  blood  as 
much  as  possible,  it  is  a  good  precaution  either  to  keep  the  limb  raised 
for  a  few  minutes  before  tlie  application  of  the  tourniquet,  or  to  bandage 
it  tightly  from  below  upwards  immediately  before  the  tourniquet  is 
applied ;  thus  preventing,  to  a  great  extent,  the  venous  congestion.  So 
soon  as  the  main  arteries  have  been  tied  after  the  removal  of  the  limb, 
the  tourniquet  may  be  unscrewed  and  taken  off;  the  assistant,  however, 
keeping  his  finger  on  the  artery  above  the  stump,  lest  any  vessels  have 
been  left  untied,  or  a  ligature  slip.  If  the  band  be  left  only  half  loosened, 
it  will  often  happen  that  venous  hemorrhage  continues  abundanth^  from 
the  stump,  in  consequence  of  the  pressure  of  the  instrument  being  still 
sufficient  to  prevent  the  return  of  the  blood  through  the  veins.  This 
will  at  once  cease  on  taking  the  tourniquet  completely  off,  and  elevating 
the  cut  surfaces. 

In  amputations  and  disarticulations,  the  Surgeon  has  the  choice  of  four 
Operative  Procedures  : — (I)  The  circular  method  ;  (2)  the  oval  method; 
(3)  flaps  of  various  sizes  and  shapes  ;  and  (4)  a  combination  of  skin-flaps 
with  a  circular  cut  through  the  muscles.  It  is  not  my  intention  to  enter 
into  a  discussion  as  to  the  relative  merits  of  the  circular  and  flap 
methods,  for  which  I  would  refer  to  the  waitings  of  Liston  and  Yelpeau. 
I  believe  that  by  either  the  circular  or  the  flap  method  an  equally  good 
stump  maj^  ultimately  be  formed  ;  but  that  much  will  depend  upon  the 
special  dexterity  which  the  Surgeon  ma}^  have  acquired  b^^  the  habitual 
performance  of  one  or  other  of  these  operations.  Educated  in  the  doc¬ 
trines  of  Liston,  wdio  invariablj^  amputated  by  the  flap  method,  and  who 
certainly  did  this  with  w'onderful  rapidit}^  and  precision,  I  have  been  in 
the  habit  of  performing  this  operation  in  preference  to  the  circular,  over 
wdiich  it  certainly  possesses  the  special  advantages  of  greater  celerity  in 
performance,  more  perfect  coaption  and  smoothness  of  the  opposite  sides 
of  the  wound,  and  a  greater  tendency  to  union  of  the  stump  b}*^  the  first 
intention.  But,  though  giving  the  preference  as  a  general  rule  to  the  flap 
amputation,  I  would  not  b}"  any  means  wdsh  it  to  be  understood  that 
I  urge  its  adoption  in  all  cases,  or  w’ould  wdsh  to  exclude  entirel}’  other 
methods  of  operating.  In  injuries,  especially,  no  one  method  can  alw'ays 
be  adopted,  the  Surgeon  often  being  obliged  to  fashion  his  stump  as  best 
he  may  in  accordance  with  the  conditions  to  which  the  limb  has  been 
reduced  by  the  injuiy  inflicted  on  it.  Many  other  points  have  to  be  con¬ 
sidered,  such  as  the  best  covering  for  the  bones,  the  best  pad  for  an 


42 


AMPUTATIONS. 


artificial  limb,  and  the  best  drainage  for  the  stump  during  the  healing 
process. 

Amputation  by  the  Circular  Method. — In  this  amputation,  the 
skin  and  fat  are  first  divided  by  a  single  sweep  of  the  knife  and  dissected 
up  for  a  distance  equal  to  half  the  diameter  of  the  limb  ;  the  muscles 
are  then  divided  by  another  circular  sweep  of  the  knife  and  retracted 
for  a  distance  vaiying  from  one  to  two  inches,  according  to  the  thickness 
of  the  limb  ;  and  the  bone  is  sawn  as  high  up  as  possible.  In  the  thigh 
and  leg  it  has  been  recommended  b}"  Hey  to  cut  the  posterior  muscles 
longer  than  the  anterior,  to  allow  for  their  greater  contraction.  The 
edges  of  the  skin  are  brought  together  in  the  transverse  diameter  of 
the  limb,  and  a  stump  is  formed  with  abundant  covering  for  the  bones, 
but  necessarily  with  some  puckering  and  projection  at  eacli  angle. 

During  the  late  Franco-Prussian  war  the  circular  was  the  method 
almost  universally  adopted  by  the  German  surgeons ;  the  advantages 
the}"  claim  for  it  being  that  much  less  care  is  required  in  the  after-treat¬ 
ment  than  in  the  flap  method,  as  the  covering  to  the  bones,  containing  no 
muscle,  is  less  liable  to  be  displaced,  and  the  patients  will  consequently 
bear  transportation  from  the  field  hospitals  at  an  earlier  period,  a  matter 
of  no  small  importance  in  militaiy  surgery ;  there  is  also  said  to  be  less 
liability  to  sloughing  than  when  the  operation  is  performed  by  long-skin- 
flaps. 

In  some  cases  of  malignant  disease,  also,  where  it  is  more  desirable 
not  to  approach  too  nearly  to  the  diseased  portion  of  the  limb,  the  cir¬ 
cular  may  be  found  to  be  a  safer  operation  than  the  flap  method,  so  far 
as  the  ultimate  condition  of  the  patient  is  concerned,  in  lessening  the 
liability  to  recurrence. 

The  oijal  method  is  especially  applicable  to  certain  amputations  and 
disarticulations  of  the  bones  of  the  hand  and  foot.  It  presents  no 
advantage  in  the  larger  amputations. 

Flap  Amputation. —  In  performing  flap  amputations,  the  Surgeon 
should  alwa3"s  stand  so  that  he  may  support  and  grasp  the  limb  to  be 
removed ;  the  left  hand  being  placed  on  the  outer  side  in  amputations 
of  the  left  limbs,  on  the  inner  side  in  those  of  the  right. 

The  Amputating  Instruments  must  be  in  proper  order,  and  of  good 
construction.  For  the  smaller  amputations  the  Surgeon  will  require 
straight  spring-backed  bistouries,  narrow  or  broad  in  the  blade,  accord¬ 
ing  to  the  size  of  the  part  to  be  removed.  Scalpels,  also,  not  too  broad 
in  the  blade,  are  useful  in  cases  in  which  the  bistouiy,  from  its  length, 
might  be  inconvenient.  Cutting-pliers,  with  long  and  strong  handles 
and  short  blades,  either  straight  or  curved,  as  ma}^  be  most  convenient, 
are  especially  required  in  amputations  about  the  hands  and  feet.  The 
knives  for  the  larger  amputations  should  have  smooth  ebony  handles, 
and  be  well  balanced.  The  back  of  the  blade  should  run  straight  to 
the  point,  and  be  well  rounded.  The  edge  should  taper  off  towards  the 
point,  with  a  good  convexity.  The  breadth  of  the  blade  should  vary 
from  I  to  f  of  an  inch,  and  its  length  should  be  proportioned  to  the 
thickness  of  the  limb  to  be  removed.  As  a  general  rule,  in  order  to 
make  a  good  sweeping  cut,  so  as  to  form  a  well-rounded  and  smooth  flap, 
the  blade  should  be  in  length  equal  to  about  double  the  thickness  of  the 
limb.  The  saw  should  be  strong  in  the  blade  and  back,  so  as  not  to 
bend  in  cutting.  The  blade  must  be  of  good  breadth,  and,  in  order  not 
to  hang  as  it  works  its  way  through  the  bone,  must  be  somewhat  thicker 
at  the  cutting  edge  than  elsewhere.  The  teeth  should  not  be  too  fine, 

o  o  _ 

and  must  be  set  crossways.  The  artery-forceps  ma}"  either  be  of  the 


FLAP  AMPUTATION. 


43 


ordinary  “bulldog”  make,  or  may  be  broad  towards  the  point,  so  as  to 
allow  the  knot  more  readil}^  to  be  slipped  over  the  vessel  to  be  tied. 

Amputations  bj"  flaps  fashioned  from  the  soft  parts  so  as  to  cover  the 
bone  and  form  a  well -cushioned  stump  may  be  performed  in  several 
diflferent  ways :  by  double  flaps,  b3^  one  long  rounded  flap,  or  bj^  one 
long  and  one  short  square  flap. 

The  Double  Flap  Amputation  is  that  which  is  usually  practised,  and 
that  which  we  shall  first  consider. 

The  two  flaps  ma^’’  be  made  either  by  cutting  from  without  inwards, 
or  by  transfixion  —  cutting  from  Tvithin  outwards.  I  generally  prefer 
transfixion  in  flesh}’’  parts,  as  the  thigh  or  arm  ;  but  cutting  from  without 
inwards  will  be  found  to  afford  the  best  result,  and  is  indeed  the  only 
mode  of  forming  the  flap,  in  some  situations  where  the  bones  are  natu¬ 
rally  thinly  covered,  as  on  the  outer  side  of  the  forearm,  the  anterior 
part  of  the  leg,  or  just  above  the  ankle-joint,  or  where  the  soft  parts 
have  been  w’asted  by  chronic  disease.  The  flaps  should  be  made  by  a 
steady  sweeping  cut,  so  that  the  soft  parts  may  be  evenly  and  smoothly 
divided.  Their  length  must  of  course  be  proportioned  to  the  thickness 
of  the  limb ;  and  on  this  point  no  positive  directions  can  be  given, 
except  that  care  be  taken  that  they  be  not  cut  too  long  nor  too  short. 
If  they  be  cut  too  long,  too  much  muscle  will  be  left  on  the  stump,  and 
the  flap  itself  is  usually  bad  fashioned  and  pointed.  Should  the  Surgeon 
feel  that  he  has  made  this  mistake,  the  wiser  plan  will  be  at  once  to 
round  off  the  ends  of  the  flaps.  Should  they  have  been  cut  too  short, 
the  soft  parts  must  be  forcibly  retracted,  and  the  bone  cleared  by  cir¬ 
cular  sweeps  of  the  knife,  and  sawn  as  high  up  as  possible. 

The  flap  farthest  from  the  vessels,  as  that  on  the  outer  side  of  the 
thigh  or  arm,  should  be  cut  first.  In  making  the  inner  flap,  great  care 
must  be  taken  to  wind  the  point  of  the  knife  w’ell  round  the  bone,  so  as 
not  to  transfix  and  split  dowui  the  vessels,  but  to  cut  them  as  long  as 
possible.  As  a  general  rule,  the  less  loose  muscle  that  is  left  on  a 
stump,  the  better:  hence,  wliere  there  is  an  equal  thickness  of  soft 
parts  round  the  bone,  as  in  the  arm  and  thigh,  the  flaps  should  be  cut 
short,  well  retracted,  and  the  bone  cleared  by  circular  sweeps  of  the 
knife  as  high  as  necessary.  The  bone  thus  lies  at  the  bottom  of  a 
conical  hollow  beyond  the  angle  of  junction  between  the  flaps,  and  there 
is  less  chance  of  a  conical  stump  being  left. 

In  1839,  Liston  proposed  a  combination  of  the  double  flap  and  cir¬ 
cular  operations,  which  greatly  improved  the  shape  of  the  stump  of  the 
circular  method,  and  somewliat  increased  the  ease  of  the  operation. 
Tw’o  semilunar  incisions,  with  their  convexities  dowuiwards,  are  made 
through  the  skin  from  side  to  side  of  the  limb  ;  the  flaps  are  then 
dissected  up  so  as  to  expose  the  muscles  as  high  as  the  angles  of  union 
of  the  flaps:  and  the  operation  is  completed  as  in  the  ordinary  circular 
method.  This  method  of  operating  is  especially  indicated  in  muscular 
parts,  such  as  the  arm,  thigh,  or  leg.  This  is  more  particularly  the  case 
where  the  amputation  is  primary,  as  then  the  piuscles  often  retract  to 
so  great  an  extent  that  it  is  difficult  to  judge  of  the  proper  length  at 
which  to  cut  them.  The  advantage  of  this  procedure  over  the  ordinary 
flap  or  the  circular  operation  is  very  great  in  certain  circumstances. 
In  both  cases,  but  more  especially  in  flap-operations  on  stout  muscular 
subjects,  a  large  pad  of  muscle  is  apt  to  be  left  in  the  stump.  This, 
w’hich  at  first  sight  might  appear  an  advantage,  as  an  additional  cov¬ 
ering  to  the  bones,  is  a  decided  disadvantage,  inasmuch  as  it  often  pro¬ 
jects  through  the  retraction  of  the  skin  covering  it,  and  is  apt  to  slough 


44 


AMPUTATIONS. 


and  interfere  'with  the  proper  union  of  the  flaps.  This  pad  is  also  dis¬ 
advantageous  after  cicatrization  is  completed,  as  at  first  it  forms  a  soft, 
flabby,  and  bulbous  end  to  the  stump,  instead  of  a  firm  hard  cicatrix; 
and  eventually  it  must  waste  and  undergo  fibro-cellular  transformation, 
before  the  stump  is  finally  consolidated.  Hence,  a  stump  that  at  first 
appears  to  be  covered  by  a  good  cushion  of  soft  pads,  will,  if  these  be 
chiefly  muscular,  gradually  shrink  and  waste,  and  may  at  last  become 
conical.  If  the  limb  have  been  the  seat  of  much  and  long-continued 
suppurative  action,  the  muscles  do  not  retract  when  cut,  but  liang  soft 
and  flaccid,  as  in  a  dead  body.  The  flaps,  therefore,  need  not  be  made 
so  long  as  in  primary  amputation  for  injury.  And  here,  also,  too  much 
muscle  is  disadvantageous,  getting  between  the  skin-flaps,  and  occa¬ 
sioning  trouble  and  delay  in  the  healing  of  the  stump. 

Amputation  hy  the  Rectangular  Flap. — The  late  Mr.  Teale,  of  Leeds, 
for  some  years  practised  amputation  by  a  long  and  a  short  rectangular 
flap,  with  the  view  of  procuring  a  more  useful  stump,  and  in  the  hope 

of  somewhat  diminishing  the 
mortality  of  the  operation. 
In  performing  amputation  by 
this  method,  the  long  flap  is 
cut  from  that  side  of  the  limb 
where  the  parts  are  generally 
devoid  of  large  bloodvessels 
and  nerves  ;  whilst  the  short 
flap  is  made  to  include  those 
structures,  which  are  cut 
across  transversely,  as  shown  in  the  annexed  figure  from  Teale.  The 
long  flap  is  perfectly  rectangular  ;  and  the  rule  for  its  formation  given 

bj^  Teale  is,  that  its  length  and 
breadth  should  each  be  equal  to  the 
half  of  the  circumference  of  the  limb 
at  the  place  of  amputation.  If  the 
circumference  be  9  inches,  the  length 
and  the  breadth  of  the  flap  should  be 
each  inches.  The  short  flap,  which 
is  always  cut  so  as  to  contain  the 
chief  vessels  and  nerves,  is  one-fourth 
of  the  length  of  the  long  one.  The 
bones  are  sawn  exactly  at  the  angle  of  union  of  the  flaps,  without  any 
previous  retractions  of  the  soft  parts.  The  vessels  are  then  tied,  and 
the  long  flap  is  folded  over  the  end  of  the  bone,  and  attached  by  sutures, 
as  in  the  a^ompanying  figure,  to  the  short  flap.  Teale  directs  that  the 
stump  thould  be  laid  on  a  pillow  lightly  covered  with  gauze  or  linen,  and 
protected  from  pressure  by  a  cradle ;  but  in  the  early  treatment  he  sa3’s 
that  no  dressings  are  required. 

The  Results  of  amputation  by  this  method  were  very  satisfactory  in 
Teale’s  hands  ;  but  more  abundant  evidence  is  required  in  order  to  show 
whether  the  mortality  of  amputations  generall}-  is  dependent  on  the 
particular  method  adopted,  rather  than  on  constitutional  causes  and 
external  influences  that  operate  equall^^  in  all  cases. 

The  rectangular  method  undoubtedly^  possesses  one  very  great  advan¬ 
tage  over  the  circular  or  ordinary  flap,  in  giving  a  soft  and  thick  covering 
to  the  ends  of  the  bones,  admitting  of  direct  bearing  upon  them ;  espe¬ 
cially  advantageous  after  the  ampution  of  the  thigh  or  leg,  when  direct 
pressure  can  scarcely  be  dispensed  with,  and  when  a  solid  firm  stump 


Fig.  4. 


Fig.  3. 


AMPUTATIOiSrS  BY  RECTANGULAR  FLAP. 


45 


admitting  it  is  of  very  essential  service  to  the  patient.  Teale  advises, 
however,  that  the  whole  pressure  be  not  borne  by  the  stump,  but  that 
it  be  reduced  to  one-half,  the  remainder  being  distributed  in  the  usual 
way  on  the  upper  part  of  the  limb  and  trunk ;  thus  not  only  relieving 
the  stump,  but  securing  greater  steadiness  of  gait  and  firmness  of  step. 
In  the  upper  extremity,  however,  no  direct  pressure  is  made  upon  the 
end  of  the  stump  in  the  adaptation  of  artificial  limbs ;  hence,  in  ampu¬ 
tations  of  the  forearm  or  arm,  a  thickly  covered  stump  is  not  so  much 
the  object  of  the  Surgeon  as  in  the  leg  and  thigh.  In  the  former 
instances,  therefore,  the  rectangular  appears  to  possess  no  advantage 
over  the  double  flap  method,  so  far  as  the  after-utility  of  the  stump  is 
concerned. 

But,  whilst  fully  admitting  the  advantage  possessed  by  the  rectangular 
method  in  the  formation  of  a  well-cushioned  stump,  especiall}^  in  the  lower 
extremit}",  we  must  not  close  our  eyes  to  certain  disadvantages  which 
appear  to  me  to  be  inseparable  from  it.  The  disadvantage  consists  in  the 
necessity  of  sawing  the  bone  at  a  higher  point  when  one  long  flap  onl}’’  is 
made,  than  when  two  shorter  ones  of  more  equal  length  are  fashioned. 
Thus,  for  instance,  in  an  amputation  of  the  thigh  for  injury  or  disease  of 
the  knee-joint,  the  long  rectangular  flap  in  an  adult  would  require  to  be 
about  eight  inches  in  length,  and  the  femur  must  consequently  be  sawn 
at  least  as  far  as  this  above  the  patella ;  whereas,  in  the  ordinary  double¬ 
flap  amputation,  two  shorter  flaps,  each  about  four  inches  in  length,  will 
be  found  sulflcieut  to  cover  in  the  bone,  which  mfxy  consequently  be  sawn 
at  a  proportionately  lower  point.  Thus  the  rectangular  method  contra¬ 
venes  one  of  the  best-established  principles  in  amputation,  viz.,  not  to 
remove  the  limb  at  a  higher  point  than  is  absolutely  necessary,  the  danger 
to  life  increasing  with  every  inch  that  is  removed :  nor  can  it  be  considered 
to  be  advantageous  in  those  cases  in  which  length  of  stump  is  essential 
to  the  after-comfort  and  utility  of  the  patient. 

In  man}’-  injuries  of  the  limbs,  also,  requiring  amputation,  the  soft 
parts  are  often  torn  in  such  a  way  that  a  good  covering  may  be  got  for 
the  stump  below  the  knee  or  elbow  by  short  double  flaps,  or  even  by  the 
circular  method,  when  there  would  be  no  possibility  of  fashioning  a  long 
flap  from  the  uninjured  soft  parts  below  those  joints ;  and  the  increased 
risk  of  high  amputation  would  have  to  be  encountered. 

In  amputations  for  malignant  disease,  also,  the  long  flap,  which  has  to 
be  cut  in  close  proximity  to  the  morbid  growth,  would  run  a  far  greater 
risk  of  infiltration  than  would  two  shorter  ones  taken  higher  up  in  the 
limb  ;  the  bone  in  both  cases  being  sawn  at  the  same  level. 

Should  union  by  the  first  intention  fail,  and  suppuration  set  in,  in  the 
rectangular  amputation,  the  thick  fleshy  mass  which  enters  into  the  con¬ 
formation  of  the  long  flap  becomes  a  source  of  great  inconvenience, 
bulging  out  from  under  the  skin,  and  requiring  considerable  management 
in  the  after-treatment. 

Spence  has  devised  a  modification  of  Teale’s  method,  b}^  which  he 
obtained  all  its  advantages  by  a  much  simpler  operation.  He  does  not 
make  a  posterior  flap,  but  compensates  for  it  by  retracting  the  soft  parts 
from  the  bones  to  an  extent  equal  to  its  length.  The  anterior  flap  is 
made  a  little  longer  than  the  diameter  of  the  limb;  and  its  angles  being 
rounded,  it  is  allowed  simply  to  hang  over  the  end  of  the  stump,  without 
being  folded  upon  itself  as  in  Teale’s  operation.  The  posterior  parts  are 
divided  from  without  inwards  by  a  single  sweep  of  the  knife.  Equally 
good  ^results  may  be  obtained,  as  suggested  by  Lister,  with  still  shorter 
flaps,  by  the  following  operation.  An  anterior  rounded  flap,  equal  in 


46 


AMPUTATIONS. 


length  to  two-thirds  of  the  diameter  of  the  limb,  is  raised  by  cutting 
from  without  inwards,  taking  with  it  as  much  muscle  as  may  be  required 
to  form  a  good  cushion  over  the  bone  ;  a  posterior  skin-flap  is  then  made 
rather  more  than  half  the  length  of  the  anterior,  also  rounded  in  shape. 
The  posterior  muscles  are  cut  as  short  as  possible,  so  as  to  set  the  flap 
free  from  the  eflects  of  their  contraction.  The  soft  parts  are  then 
retracted  for  about  two  inches  and  the  bone  sawn.  By  these  means  all 
the  advantages  claimed  b}^  Teale  for  this  method,  viz.,  a  good  covering, 
a  dependent  opening  for  discharges  and  a  cicatrix  free  from  pressure 
from  the  end  of  the  bone,  are  obtained  with  the  smallest  possible  sacrifice 
in  the  length  of  the  limb.  As  by  all  these  methods  the  cicatrix  is  some 
way  posterior  to  the  end  of  the  bone,  the  patient  is  capable  of  bearing  a 
certain  portion  of  his  weight  directl}-  on  the  end  of  the  stump,  which 
gives  great  increased  steadiness  and  power  in  the  use  of  the  artificial 
limb. 

Amputation  by  one  Long  Flap. — In  some  amputations,  as  at  the 
shoulder  and  hip-joints,  owing  to  the  anatomical  configuration  of  the 
parts,  onh"  one  long  flap  can  be  made.  And  in  others,  as  in  the  removal 
of  the  fingers  through  a  phalangeal  articulation,  or  of  the  metatarsal 
bone  of  the  great  toe,  it  is  found  more  convenient  to  make  but  one  long 
flap,  cutting  through  the  soft  parts  transversely  on  the  opposite  side  of 
the  limb.  This  method  has  been  extended  by  some  Surgeons  to  all  arn- 
jnitations,  but  it  appears  to  me  to  possess  no  advantage  over  the  double 
flap,  and  to  be  attended  by  the  same  inconvenience  as  that  which  accom¬ 
panies  Teale’s  method. 

Sawing  the  Bone. — So  soon  as  the  incisions  have  been  made  through 
the  soft  parts,  the  bones  must  be  cleared  for  the  application  of  the  saw. 
This  is  best  done,  when  there  is  onl}’  a  single  bone,  by  a  firm  circular 
sweep  of  the  knife  from  heel  to  point  round  the  under  segment  of  the 
bone,  and  then  another  round  the  upper  surface  in  the  opposite  direc¬ 
tion.  If  there  be  two  bones,  care  must  be  taken  in  clearing  them  not 
to  direct  the  edge  of  the  knife  upwards  into  the  interosseous  space 
higher  than  the  line  to  which  the  saw  is  to  be  applied,  lest  any  artery  be 
cut  where  it  will,  on  account  of  its  retraction,  be  difficult  to  secure  it. 

The  bone  having  been  properly  cleared,  tlie  flaps  must  be  firmly  re¬ 
tracted  by  an  assistant,  in  order  to  allow  the  saw  to  be  applied  opposite 
the  highest  point  of  the  incision  through  the  soft  parts.  For  the  pur¬ 
pose  of  retraction,  the  assistant’s  hands  are  quite  sufficient,  though  some 
surgeons  still  use  retractors^'^  made  of  split  pieces  of  linen  cloth  or  of 
wash-leather.  But,  although  “retractors”  may  not  be  required  for  the 
purpose  of  drawing  back  the  soft  parts,  they  are  of  great  use  in  pro¬ 
tecting^  the  muscles  from  the  teeth  of  the  saw  and  from  the  bone-dust 
produced :  for  the  laceration  of  the  deep  muscles  by  the  saw,  and  the 
imbedding  of  particles  of  bone-dust  in  their  substance,  interfere  seri- 
ouslj’  with  union.  In  order  to  saw  the  bone  quickl}’  and  steadil}’,  there 
are  several  points  deserving  attention.  The  first  cut  should  be  made  so 
as  to  form  a  deep  groove  to  receive  the  teeth  :  to  do  this,  the  heel  of  the 
saw  is  steadied  against  the  left  thumb,  which  is  pressed  on  the  bone  ; 
and  the  instrument  is  drawn  fairh^  and  sharply  along  the  whole  line  of 
its  teeth  from  heel  to  point.  The  groove  thus  formed  receives  the  edge 
of  the  saw ;  and  the  bone  may  then  be  quickly  cut  through  by  long, 
light,  and  sweeping  movements  of  the  instrument  from  point  to  heel, 
the  position  being  gradually  changed  from  the  horizontal  to  the  vertical 
as  progress  is  made.  The  Surgeon  must,  with  his  left  hand,  support 
carefully  the  part  to  be  removed ;  neither  depressing  it,  so  as  to  snap 


AKREST  OF  HEMORRHAGE. 


47 


the  bone  as  it  is  weakened  b}"  sawing;  nor  raising  it  so  as  to  run  the  risk 
of  locking  the  saw.  When  there  are  two  bones  in  the  limb  of  equal 
strength,  as  in  the  forearm,  they  should  be  cut  through  at  the  same  time  ; 
but  in  the  leg,  the  fibula,  being  the  weakest,  should  always  be  first 
divided.  Should  the  division  be  made  irregularljq  and  splinters  of  bone 
project,  these  must  be  snipped  off  with  cutting-pliers. 

Arrest  of  Hemorrhage. — After  the  limb  has  been  removed,  the  first 
thing  to  be  done  is  to  restrain  arterial  hemorrhage.  This  may  be  effected 
by  one  of  three  methods  :  ligature,  acupressure,  or  torsion.  If  ligatures 
be  used,  the  main  and  larger  arteries  must  first  be  tied.  For  this  pur¬ 
pose,  fine  compressed  whipcord  is  the  best  material.  The  ends  of  these 
ligatures,  knotted  together,  must  be  left  long,  so  that  they  ma}^  be  dis¬ 
tinguished.  Usually  from  two  to  four  or  six  smaller  vessels  require  to 
be  tied,  and  they  should  be  secured  with  ordinaiy  ligature-thread  ;  but 
sometimes,  either  from  the  existence  of  malignant  disease,  or  of  exten¬ 
sive  suppurative  action  in  the  limb,  the  stump  is  excessively  vascular, 
and  a  veiy  large  number  of  ligatures  may  be  required.  I  have,  in  these 
circumstances,  more  than  once  had  occasion  to  apply  between  twenty 
and  thirt\'  ligatures  to  vessels  in  the  arm  and  thigh.  As  union  always 
takes  place  by  granulation  in  such  cases,  it  signifies  little  how  many 
ligatures  are  put  on,  the  smaller  ones  separating  early.  One-half  of 
each  ligature  should  be  cut  off  close  to  the  knot,  and  the  single  threads 
thus  left  must  be  brought  out  at  the  lower  angle  of  the  wound,  through 
which  any  discharge  that  may  form  may  drain  away.  Silver  or  iron 
wire  may  be  used  for  ligating  the  arteries,  with  the  view  of  preventing 
the  suppuration  that  results  from  the  irritation  of  the  ordinary  silk  or 
thread  ligatures,  and  thus  facilitating  union  by  the  first  intention.  I 
have  employed  them  in  several  instances,  but  have  found  that  they  do 
not  cut  through  the  artery  as  the  thread  does,  and  consequently  do  not 
detach  themselves,  but  require  to  be  pulled  or  twisted  off — a  procedure 
which  may  be  attended  by  hemorrhage.  The  practice  of  cutting  the 
ends  of  ligatures  short,  whether  hempen  or  metallic,  is  most  objection¬ 
able  ;  for,  although  the  stump  may  heal  over  them,  they  eventually 
become  sources  of  irritation,  and  set  up  suppuration  or  develop  neu¬ 
ralgia. 

Acupressure,  and  torsion  of  the  ends  of  cut  arteries,  are  often  em¬ 
ployed  instead  of  the  ligature  by  the  advocates  of  these  methods.  For 
a  detail  of  the  mode  of  arresting  hemorrhage  by  these  means,  and  for 
a  comparison  of  their  merits  with  those  of  the  ligature,  I  must  refer 
to  Chapter  XIY. 

Free  arterial  bleeding  will  sometimes  take  place  from  a  point  in  the 
cut  surface  of  the  bone,  in  consequence  of  the  division  of  the  trunk  of 
the  nutritious  artery.  This  hemorrhage  is  best  arrested  by  pressing  a 
small  wooden  plug  into  the  bleeding  bone.  To  this  a  piece  of  wire 
should  be  attached,  so  that  it  may  be  drawn  out  when  loosened  by  sup¬ 
puration  at  the  end  of  a  few  days. 

The  mode  of  union  of  the  flaps  of  a  stump,  the  dressings  required, 
and  the  general  management  of  the  part  after  an  amputation,  differ  in 
no  respect  from  what  takes  place  in  the  healing  of  primary  incised 
wounds,  to  be  hereafter  described. 

Sutures  may  be  either  of  well-waxed  silk  or  of  metallic  wire.  They 
should  be  introduced  through  the  lips  of  the  incision  at  intervals  of 
an  inch :  care  being  taken  to  leave  the  most  dependent  angles  of  the 
stump  open,  and  to  draw  out  the  ligatures  through  them.  In  cases 
of  primary  amputation  for  injury,  or  in  any  case  in  which  oozing  is 


48 


AMPUTATIONS. 


expected,  the  sutures  should  he  introduced  whilst  the  patient  is  under 
chloroform,  and  left  loose.  When  this  is  done,  silken  sutures  must  be 
emplo3’ed,  and  wet  lint  applied  between  the  surfaces  and  over  the  out¬ 
side,  the  dressing  of  the  wound  being  deferred  for  a  few  hours,  until 
the  surfaces  are  glazed.  But  in  amputations  for  disease,  when  patients 
are  in  a  low  and  irritable  condition,  I  think  it  better  to  applj^  the 
dressings  immediately  after  the  performance  of  the  amputation,  before 
the  effects  of  the  chloroform  are  recovered  from.  In  these  cases  metallic 
sutures  should  be  employed;  they  are  less  irritating,  and  may  be  re¬ 
tained  longer.  Before  dressing  the  stump,  it  is  desirable  that  all  oozing 
should  have  ceased,  lest  a  coagulum  form  between  the  flaps,  and  so 
interfere  with  union;  with  this  view,  a  jug  or  two  of  cold  water  may 
be  poured  over  the  face  of  the  stump.  The  dressings  should  then  be 
applied.  They  should  be  as  light  and  unirritating  as  possible.  The 
object  that  we  have  in  view  is  the  union  of  the  flaps  as  speedily  as  pos¬ 
sible — not  onl}^  along  their  edges,  but  throughout  the  deeper  portion  of 
the  stump.  Strips  of  adhesive  plaster,  about  fifteen  inches  long,  should 
be  applied  between  the  points  of  suture,  and  the  stump  bandaged  from 
the  upper  part  of  the  limb  as  far  as  the  line  of  incision,  so  as  to  bring 
together  the  deeper  parts  of  the  wound,  more  particularly  where  the 
bone  intervenes  between  the  flaps.  A  piece  of  wet  lint,  kept  constantly 
moist  with  cold  carbolized  water,  should  then  be  laid  over  the  line  of 
incision,  the  stump  comfortably  supported  on  pillows,  and  the  weight  of 
the  bedclothes  taken  off  b}^  a  cradle.  After  this,  it  should  be  disturbed 
as  little  as  possible  for  a  few  da3’s.  The  carbolized  lint,  which  will  be¬ 
come  soiled  b}’  a  reddened  sero-sanguinolent  discharge,  must  be  changed 
every  few  hours. 

Union  b^’  the  “first  intention”  can  onl^^  be  expected  to  take  place  in 
certain  amputations,  and  even  in  them  not  wholl}-  and  entirelj".  When 
the  bone  is  very  large,  as  the  femur,  an  angle  is  apt  to  be  left  between 
the  flaps  and  the  apex  of  the  stump,  which  bj’  preventing  complete  coap¬ 
tation  at  this  point,  renders  direct  union  impossible  ;  so  also,  if  a  cavit}’’ 
exist  in  the  bone,  as  the  glenoid  or  cotyloid,  in  amputation  at  the  shouler 
and  hip,  there  will  necessarily^  be  suppuration.  Then,  again,  muscle  will 
not  adhere  directly^  to  syuiovial  membrane  or  to  cartilage  in  disarticula¬ 
tions,  and  in  many  cases  not  even  to  the  cut  surface  of  bone.  In  fact, 
for  all  these  reasons,  independently^  of  any"  constitutional  causes,  complete 
primary  union,  or  that  by*  the  “  first  intention,”  is  much  more  rare  than 
is  commonly  supposed,  and  is  more  frequently^  talked  about  than  seen 
in  amputations.  However,  whatever  portion  of  the  stump  unites  directly 
and  primarily  is  so  much  gained,  and  no  effort  should  be  left  untried  to 
secure  so  desirable  a  result. 

When  suppuration  sets  in,  warm-water  dressings  should  be  substituted 
for  the  cold  lint,  and  eveiy  possible  attention  should  be  paid  to  cleanliness 
by"  a  frequent  change  of  the  dressings,  more  especially  in  warm  weather. 

Erysipelas^  with  a  more  or  less  sloughy  condition  of  the  stump^  not 
unfrequently^  occurs.  In  such  cases  all  sutures  should  be  at  once 
taken  out,  and  the  strips  of  plaster  either  taken  off  or  reduced  to  two, 
put  on  lightly  so  as  merely"  to  aflford  some  degree  of  support.  The 
stump  should  be  enveloped  in  soft  poultices,  and  well  washed  with  warm 
water  or  disinfecting  fluids  at  each  change  ;  great  care  being  taken  not  to 
allow  matter  to  be  confined,  or  to  loosen  the  ligatures.  The  constitu¬ 
tional  treatment  of  the  case  must  be  conducted  on  the  principles  that 
will  be  detailed  in  the  chapter  on  Erysipelas  ;  but,  as  a  general  rule,  it 
should  be  tonic  and  stimulating,  dietetic  rather  than  medicinal.  Should 


AMPUTATION  OF  TWO  LIMBS. 


49 


secondary  hemorrhage  occur,  it  must  be  treated  as  will  be  hereafter 
described. 

When  suppuration  is  subsiding,  and  cicatrization  going  on,  the  bandage 
may  advantageously  be  brought  over  the  face  of  the  stump.  As  a  general 
rule,  it  will  be  found  that  a  narrow  roller  will  adapt  itself  better  than  a 
broad  one.  After  cicatrization  is  completed,  the  patient  should  be  allowed 
to  go  about  on  crutches,  but  must  not  wear  an  artificial  limb  for  several 
months,  until  the  parts  have  become  firmly  consolidated ;  during  the 
whole  of  this  time  the  stump  should  be  kept  carefully  bandaged,  and  not 
exposed  to  injury. 

Simultaneous  or  Rapidly  Consecutive  Amputation  of  Two 
Limbs,  requiring  removal  for  severe  injury  or  for  gangrene,  has  occa¬ 
sionally  been  successfully  practised,  either  by  two  Surgeons  performing 
the  two  amputations  at  the  same  time ;  or  by  the  same  Surgeon  doing 
first  one  and  then  the  other,  the  vessels  of  the  first  limb  being  secured 
by  an  assistant,  whilst  the  second  limb  is  being  removed.  The  circula¬ 
tion  through  both  lower  extremities  may  be  completely  arrested  by  com¬ 
pressing  the  aorta  by  means  of  Lister’s  tourniquet.  By  means  of  this 
valuable  instrument,  I  have  amputated  both  thighs  in  close  succession 
without  waiting;  for  the  lig:ature  of  the  arteries  in  that  wLich  was  first 

o  o 


Fig.  5. 


Fig.  C. 


removed.  The  object  in  two  simultaneous  amputations  is  to  lessen  the 
continuance  of  shock  to  tlie  system,  by  throwing,  as  it  were,  that  of  the 
two  operations  into  one.  In  doing  this,  however,  the  Surgeon  must 
necessarily  be  guided  b}^  the  circumstances  of  the  case.  If  the  patient 
were  very  greatly  depressed,  the  infliction  of  so  severe  an  injury  as  a 
double  amputation  might  probably  extinguish  life  at  once ;  and,  if  it 
were  possible  to  wait  after  the  removal  of  the  first  limb,  until  the  shock 
of  the  operation  had  passed  off,  before  the  second  was  amputated,  it 
might  be  desirable  to  do  so ;  but  if  the  patient  were  not  too  much 
depressed,  the  simultaneous  or  rather  rapidly  consecutive  double  ampu¬ 
tation  would  probably  be  the  safer  course. 

Stumps. — On  examining  the  Structu7'e  of  a  Stump,  after  a  year  or 
two  have  elapsed  from  the  time  of  its  formation,  it  will  be  found  to  be 
composed  of  a  mass  of  fibro-cellular  tissue, 
the  muscular  and  tendinous  structures  that 
enter  into  its  formation  having  become  thus 
transformed.  The  ends  of  the  bones  will 
be  found  to  be  rounded,  and  the  medullary 
canal  filled  up,  the  vessels  being  obliterated 
up  to  the  nearest  collateral  branch  (Fig.  5). 

The  ends  of  the  nerves  are  thickened,  and 
commonly  assume  a  bulbous  appearance 
(Fig.  6).  On  examining  these  rounded  or 
oval  tumors,  they  will  be  found  to  be  fibro- 
cellular  masses,  having  nervous  fibrillse 
thinly  scattered  throughout. 

The  proper  adaptation  of  Artificial  Limbs 
is  a  matter  of  considerable  consequence; 
and  the  ingenious  mechanical  contrivances 
that  are  at  the  present  day  adapted  to 
stumps,  leave  little  to  be  desired.  The 
Surgeon  had  better  leave  the  details  of 
these  mechanical  contrivances  to  the  in¬ 
strument-maker  ;  but  he  should  see  that 

they  are  made  light,  consistently  with  sufficient  strength  and  support, 
VOL.  I. — 4 


Artery  of  Thigh- 
stump  laid  open. 


Nerve  in  a  Stump 
of  Forearm. 


50 


AMPUTATIONS. 


Fig.  7. 


and  that  the  end  of  the  stump  is  never  pressed  upon  by  them.  Thus, 
after  amputation  of  the  thigh,  the  artificial  limb  should  take  its  bearing 
point  from  the  lower  part  of  the  pelvis  and  hip.  In  amputation  imme- 
diatel}^  below  the  knee,  this  joint  should  be  bent  and  received  into  the 
socket  of  the  instrument ;  and,  if  the  amputation  be  at  a  lower  point 
than  this,  and  the  stump  be  extended  into  the  artificial  limb,  its  end  must 
be  protected  from  injurious  pressure.  Even  in  the  case  of  disarticulation 
at  the  ankle-joint,  where  the  soft  tissues  of  the  heel  are  left,  pressure  can 
seldom  be  borne  upon  the  end  of  the  stump. 

Morbid  Conditions  of  Stumps. — Necrosis. — It  not  unfrequently 
happens  that  the  end  of  the  bone  in  a  stumi)  dies.  Most  commonly  this 
is  the  consequence  of  inflammation  (osteo-myelitis)  set  up  in  that  portion 
of  the  bone  which  is  left  in  the  stumj),  as  the  result  of  wiiich  its  vitality 
is  lost  and  necrosis  sets  in  ;  or  it  may  occur  in  consequence  of  the  injury 
inflicted  by  the  jarring  of  the  saw.  This  is  especially  apt  to  happen  in 
persons  of  feeble  constitution,  in  wdiom  the  limb  has,  previously  to  the 
operation,  been  the  seat  of  abscess  that  has  denuded  the  bone  or  other¬ 
wise  injured  its  vitality.  In  these  cases  a  fistulous  opening  will  be  left 
leading  down  to  the  necrosed  bone,  which  usually  separates  three  or  four 
months  after  the  operation  in  the  shape  of  a  complete  ring,  with  irregu¬ 
larly  spiked  prolongations  stretching  from  its  upper 
part  (Fig.  7)  ;  after  this  has  been  removed,  the  stump 
becomes  firmly  consolidated.  The  lower  part  of  such 
a  sequestrum  is  thick  and  annular,  and  includes  the 
whole  tliickness  of  the  bone.  It  is  smooth  externallj’, 
wliere  it  has  been  covered  by  the  periosteum.  About 
an  inch  above  this  it  becomes  thinner,  and  is  composed 
of  the  innermost  part  of  the  bone — that  which  sur¬ 
rounds  the  medullary  canal.  Then  it  is  roughened 
externally,  where  it  has  separated  from  the  adjacent 
healthy  bone ;  and  above  this  it  is  spiculated  and 
very  irregular,  becoming  gradually  thinner.  In  some 
cases  the  spiculated  part  is  very  sharp-edged ;  in 
others,  as  in  Fig.  7,  it  is  somewhat  smoothed  by  long 
contact  with  the  pus  that  has  surrounded  it. 

Conical  or  “  Sugar-loaf  Stumps,  as  they  are  called, 
commonly  form  either  in  consequence  of  the  flaps  hav¬ 
ing  originally  been  cut  too  short,  or  from  the  bone 
not  having  been  sawn  off  sufficiently  high  above  the 
angle  of  the  flaps  ;  but  in  other  cases  they  may  occur, 
though  the  stump  has  been  skilfully  fashioned,  ip 
consequence  of  the  soft  parts,  which  have  been  the 
seat  of  inflammatory  action  and  suppuration  before 
the  amputation,  retracting  during  the  granulating 
process  so  as  to  denude  the  bone.  In  such  cases  as 
these,  great  retraction  and  contraction  of  the  flaps 
are  apt  to  go  on  during  cicatrization,  so  that  the  bone  may  never  be 
covered  at  all,  but  be  exposed  at  the  bottom  of  an  irritable  ulcer ;  or,  if 
the  soft  parts  do  coalesce,  the  cicatrix  will  be  unable  to  support  the 
slightest  pressure  without  becoming  ulcerated.  In  these  circumstances, 
the  only  remedy  eonsists  in  laying  open  the  stump,  and  cutting  off  about 
three  inches  of  the  bone. 

If  the  stump  be  too  long  and  projecting,  so  as  constantly  to  be  in  the 
patient’s  way,  there  is  no  remedy  but  to  perform  a  second  amputation 
higher  up.  This  is  especially  required  in  badly  fashioned  stumps  of  the 


Necrosed  end  of  Femur 
from  Stump. 


MORBID  CONDITIONS  OF  STUMPS. 


51 


leg,  where  the  liml)  has  been  removed  too  far  below  the  knee,  so  that  it 
projects  backwards  in  an  awkward  manner,  and  is  constantly  liable  to 
accident  when  the  patient  uses  a  wooden  pin. 

Aneurismal  Enlargement  of  the  arteries  of  a  stump  is  extremel}’’  rare. 
The  only  case  with  which  I  am  acquainted  is  one  described  by  Cadge,  in 
which  an  aneurisma 

varix  between  the  pos-  Fig.  8, 

terior  tibial  artery  and 
veins  formed  in  a  stump 
after  disarticulation  of 
the  ankle-joint  (Fig. 

8,  a). 

Painful  and  Spas¬ 
modic  Stumjjs. — The 

nerves  in  a  stump  natu-  Aneurismal  Varix  in  a  Stump, 

rally  become  somewhat 

expanded  and  bulbous ;  and  no  material  inconvenience  results  from 
this  condition.  But  it  occasionally  happens  that  a  distinct  tuberose  en¬ 
largement  forms  in  connection  with  one  of  them,  and  attains  the  size  of 
a  cherry  or  a  walnut ;  and,  this  being  pressed  against  the  end  of  the  bone, 
the  stump  becomes  the  seat  of  intense  pain  of  a  neuralgic  character, 
more  particularly  whenever  it  is  touched,  when  a  sensation  like  an  electric 
shock  is  felt.  In  such  circumstances,  excision  of  this  bulbous  extremity 
of  the  nerve,  or  resection  of  the  stump  so  as  to  remove  the  end  of  the 
bone  and  the  whole  of  the  cicatrix,  is  necessary,  and  will  effect  a  cure. 
Sometimes  a  nervous  twdg  may  become  implicated  in,  and  compressed  by, 
the  cicatrix.  Here  a  more  limited  excision  will  remove  the  pain.  Be¬ 
sides  this  form  of  painful  stump,  which  may  happen  in  the  strongest  and 
healthiest  subjects,  and  is  entirely  dependent  on  local  causes,  there  is 
another  condition  in  which  the  stump  becomes  not  only  the  seat  of  intense 
pain,  but  of  continuous  convulsive  twdtchings.  This  form  of  painful 
stump  arises  from  constitutional  causes,  and  most  frequently  occurs  in 
females,  more  particularly  in  those  who  are  of  the  hj^sterical  tempera¬ 
ment,  and  are  or  have  been  subject  to  neuralgic  pains  elsewhere.  In 
these  cases  the  general  cutaneous  sensibility  of  the  stump  is  increased ; 
it  is  the  seat  of  convulsive  jerkings  or  twitchings,  and  the  pain  is  more 
or  less  intermittent,  being  increased  under  the  influence  of  various  emo¬ 
tional  and  constitutional  causes.  In  such  cases,  the  treatment  should  be 
conducted  on  the  general  principles  that  will  be  fully  discussed  when  we 
come  to  speak  of  neuralgia.  No  excision  of  the  nerves  of  the  stump, 
or  even  amputation  higher  up,  is  of  an}^-  avail:  the  disease,  being  consti¬ 
tutional,  will  certainly  return  in  each  successive  stump,  lentil  at  last  the 
shoulder  or  the  hip  may  be  reached  without  any  permanent  benefit  to 
the  patient. 

Strumous  or  Malignant  Degeneration  may  occur  in  a  stump,  present¬ 
ing  the  ordinary  characters  of  tliese  affections  met  with  elsewhere.  In 
the  strumous  stump,  secondary  amputation  may  advantageously  be  per¬ 
formed;  but  on  the  recurrence  of  malignant  disease  it  is  seldom  justifi¬ 
able,  as  there  is  probably  deposit  in  internal  organs  or  contamination 
of  the  lymphatics. 

Fatty  Degeneration  of  the  muscles  of  a  limb,  arising  from  their  disuse, 
gives  rise  to  a  peculiar  appearance  in  the  stump.  During  the  amputation, 
the  muscles  look  like  pieces  of  yellow  wax,  and  are  firm ;  no  atrophy,  so 
far  as  size  is  concerned,  has  taken  place ;  the  fat  being  deposited  between 
the  muscular  fibres,  producing  atrophy  of  them  by  its  pressure,  and 


52 


AMPUTATIONS. 


occupying  their  place,  so  that  the  general  size  of  the  limb  and  fulness 
of  the  stump  are  preserved.  Union  takes  place  in  these  circumstances, 
though  somewhat  slowly  ;  at  least,  this  has  occurred  in  several  cases  in 
which  I  have  observed  this  condition.  In  one  of  these  I  amputated  the 
leg  for  disease  of  the  foot  of  nine  years’  standing,  and  in  another  the 
thigh  for  disease  of  the  knee  of  fourteen  years’  standing. 

Mortality  after  Amputation. — The  general  causes  of  death  after 
operations  have  already  been  considered ;  but  we  must  now  examine 
some  special  points  connected  with  the  relative  mortality  after  amputa¬ 
tions  of  different  kinds,  and  the  cause  of  the  difference  that  exists.  The 
principal  causes  of  death  after  amputation  are  the  influence  of  shock,  the 
occurrence  of  secondary  hemorrhage,  pyaemia,  erysipelas,  phlebitis,  and 
congestive  pneumonia ;  besides  these,  hospital  gangrene  and  sloughing 
of  the  stump  occasionally  carry  off  the  patient.  Pyaemia  is  the  most 
frequent  cause  of  death  after  amputations,  nearly  one-half  of  the  patients 
that  die  perishing  from  this  disease.  Bryant  has  shown,  that,  at  Gu3^’s 
Hospital,  it  is  fatal  in  ten  per  cent,  of  all  amputations,  and  in  forty-two 
per  cent,  of  fatal  cases,  and  that  it  is  most  frequent  after  amputations 
through  limbs,  the  tissues  of  which  are  in  a  normal  condition,  and  where 
a  large  surface  of  healthy-  bone  is  exposed,  as  in  amputations  for  injury, 
and  in  the  removal  of  limbs  for  tumors,  talipes,  ank^dosis,  etc.  It  is  not 
so  common  after  amputations  performed  for  chronic  joint  disease.  Shock 
is  a  frequent  cause  of  death  after  primaiy  amputation  of  the  larger 
limbs. 

The  circumstances  "which  more  specially  influence  the  general  result  of 
amputations,  as  well  as  the  particular  cause  of  death  after  the  operation, 
ma}^  be  divided  into  two  classes :  a.  Those  that  have  reference  to  the 
general  constitutional  condition  of  the  patient.  (3.  Those  that  are  con¬ 
nected  with  the  operation  itself. 

a.  To  the  first  class  ma^’'  be  referred,  I,  Age  ;  2,  General  Health ;  and  3, 
Hygienic  Conditions. 

1.  exercises  a  material  influence  on  the  result  of  amputations.  As 
a  general  rule  it  may  be  stated  that  the  younger  the  patient,  the  greater 
the  likelihood  of  a  successful  result.  At  early  periods  of  life,  also, 
there  is  a  great  exemption  from  low  secondary  diseases  of  the  eiysipela- 
tous  tyq^e ;  and,  if  death  occur,  it  is  usually  from  exhaustion  or  inter¬ 
current  visceral  mischief. 

2.  The  General  Health  of  the  patient  previously  to  the  operation 
exercises  necessarity  a  most  powerful  influence  on  the  chances  of  recovery. 
The  state  of  the  kidne^^s,  more  especialty,  is  of  great  importance  in  this 
respect ;  for  no  condition  tends  more  certainly  to  a  fatal  termination, 
than  a  chronically  diseased  state  of  those  organs.  The  results  of  am¬ 
putation  are  also  necessarily  widety  different,  according  as  the  operation 
is  practised  on  the  healthy-  inhabitants  of  a  country  district,  or  on  the 
cachectic  and  debilitated  denizen  of  a  large  towm.  The  causes  of  death 
also  differ  in  these  cases.  In  the  countiy,  hemorrhage  or  acute  inflam¬ 
mation;  in  towns,  exhaustion,  eiysipelatous  diseases,  and  p^^semia, 
commonly  lead  to  the  fatal  result. 

3.  The  Hygienic  Conditions  that  surround  the  patient  after  the  ope¬ 
ration  exercise  perhaps  an  equally  important  influence,  not  onty  on  the 
rate  of  mortality,  but  on  the  cause  of  death.  Exposure  to  an  impure 
atmosphere,  want  or  bad  quality  of  food  after  amputation,  lessen  mate- 
rialty  the  prospect  of  recovery,  by  disposing  the  patient  to  the  worst 
forms  of  eiysipelas,  p^^semia,  and  hospital  gangrene.  The  question, 
whether  large  hospitals  exercise  an  injurious  influence  on  the  result  of 


MOKTALITY  AFTER  AMPUTATION. 


53 


amputations,  has  been  much  debated  of  late  years.  Sir  James  Simpson 
collected  statistics  to  show  that  the  mortality  was  great  in  the  large 
town  hospitals,  small  in  provincial  hospitals  in  proportion  to  their  size, 
and  least  of  all  in  cases  occurring  in  private  practice.  This  statement 
has  been  contested  and  proved  to  be  erroneous  by  several  Surgeons ; 
among  them  b}^  Callender,  who  asserts,  that  in  St.  Bartholomew’s  Hos¬ 
pital  the  average  mortality  among  patients  admitted  from  the  country  is 
about  the  same  as  that  of  patients  in  countiy  hospitals,  being  in  each 
case  less  than  that  of  inhabitants  of  London  admitted  into  the  hospital. 

/3.  The  circumstances  connected  with  the  operation  itself  that  influence 
materiall}'  its  result,  are,  1.  The  Seat  of  the  amputation.  2.  The  Structure 
of  the  Bone  sawn.  3.  Whether  the  operation  is  done  for  Injury  or 
Disease.  4.  If  for  disease,  the  Nature  of  the  afiection.  5.  If  for  injury, 
the  Time  that  has  elapsed  before  the  limb  is  removed. 

I.  With  regard  to  the  influence  of  the  Seat  of  amputation  on  the 
result  of  the  operation,  it  may  be  stated  as  a  general  rule,  that  the  risk 
is  greater  in  proportion  as  the  size  of  the  part  that  is  amputated 
increases,  and  as  the  line  of  amputation  approaches  the  trunk ;  in  fact, 
the  nearer  it  is  to  the  trunk,  the  greater  is  the  danger.  In  the  larger 
limbs,  more  especiall}"  in  the  thigh,  every  additional  inch  that  is  removed 
appears  to  make  a  difiference  in  this  respect.  Thus,  in  our  army  in  the 
Crimea,  of  178  amputations  of  the  thigh  44  w'ere  in  the  upper  third,  and 
of  these  38,  or  86  per  cent,  proved  fatal ;  68  were  in  the  middle  third, 
and  of  these  41,  or  60  per  cent.,  died;  whilst  in  the  lower  third  the 
mortalit}"  out  of  66  cases  was  37,  or  56  per  cent. 

It  needs  no  formal  argument  to  show  that  the  amputation  of  the  toe 
or  of  the  foot  is  less  hazardous  than  that  of  the  leg  or  the  thigh.  The 
subjoined  table,  derived  from  the  examination  of  statistics  of  ampu¬ 
tations  in  civil  practice,  collected  from  various  British,  Continental,  and 
American  sources,  shows  clearly  the  increase  in  the  ratio  of  mortality 
as  the  operation  approaches  the  trunk.^ 


SEAT. 

CASES. 

DEATHS. 

PER  CENT. 

Shoulder-joint . 

117 

58 

49.5 

Arm . 

1319 

375 

28.4 

Forearm . . 

1059 

109 

10.2 

Hip-joint . 

46 

19 

41.3 

Thigh . 

3477 

1224 

35.2 

Leg . 

3006 

985 

32.7 

If  we  turn  to  the  statistics  of  militaiy  surgeiy,  we  And  similar  results. 
Thus,  in  the  British  army  in  the  Crimea  the  percentages  of  death  were, 
after  amputation  of  the  forearm,  7 ;  of  the  upper  arm,  19 ;  of  the  shoul¬ 
der-joint,  35;  of  the  foot,  16;  of  the  leg,  37  ;  of  the  knee,  57  ;  of  the 
thigh,  64 ;  and  of  the  hip,  100 ;  flgures  most  creditable  to  the  skill  of 
the  Surgeons  employed,  but  showing  the  progressive  tendency  to  increase 

*  The  numbers  referred  to  in  this  Chapter  have  been  derived  in  great  part  from 
the  elaborate  Tables  published  by  Mr.  James  Lane  in  the  first  volume  of  the  last 
edition  of  Cooper’s  Surgical  Dictionary :  Sir  J.  Y.  Simpson’s  paper  on  Hospitals, 
in  the  Edinburgh  Medical  Journal  for  June,  1869  :  various  statistical  papers  in  the 
Reports  of  Hospitals  :  M,  Chenu’s  elaborate  special  returns  on  the  medical  service 
of  the  French  army  in  the  Crimean  War,  and  in  the  Italian  Campaign:  and  the 
official  reports  issued  by  the  Surgeon-General  of  the  United  States  Army  regarding 
the  War  of  the  Rebellion. 


54 


AMPUTATIONS 


with  the  size  of  the  limb  removed.  In  the  French  army  in  the  Crimea, 
the  percentage  of  mortality  after  amputation  of  the  forearm  was  45  ;  of 
the  arm,  55  ;  of  the  shoulder-joint,  61  •,  of  the  foot,  16  ;  of  the  leg,  12;  of 
the  knee-joint,  91 ;  of  the  thigh,  92  ;  and  of  the  hip,  100.  In  the  Italian 
campaign  of  1859,  the  percentages  of  the  mortality  in  the  French  army 
— including  in  some  cases  operations ‘on  wounded  Austrians — were:  fore¬ 
arm,  42  ;  arm,  56  ;  shoulder-joint,  55  ;  foot,  55  ;  leg,  70  ;  knee-joint,  75  ; 
thigh,  78;  hip-joint,  57.  In  the  war  of  tlie  American  rebellion  the  per¬ 
centages  of  mortality  were  as  follows,  showing  markedly  how  rapidly  it 
runs  up  in  accordance  with  the  size  of  the  part  removed  :  fingers  and  hand, 
1.6  ;  wrist,  5.5  ;  forearm,  16.5  ;  arm,  21.2  ;  shoulder,  39.2  ;  partial  of  foot, 
9.2  ;  ankle-joint,  13.4  ;  leg,  26  ;  knee,  55  ;  thigh,  64.4  ;  hip,  85.7. 

Not  only  is  there  this  increase  in  the  rate  of  mortality  as  the  operation 
approaches  the  trunk,  but  in  the  larger  limbs,  more  especially  in  the 
thigh,  every  additional  inch  that  is  removed  appears  to  make  a  difference 
in  this  respect.  Thus,  in  our  army  in  the  Crimea,  of  178  amputations  of 
the  thigh,  44  were  in  the  upper  third,  and  of  these  38,  or  86  per  cent., 
proved  fatal ;  68  were  in  the  middle  third,  and  of  these  41,  or  60  per 
cent.,  died ;  whilst  in  the  lower  third  the  mortality  out  of  66  cases  was 
37,  or  56  per  cent.  In  the  French  army  in  the  Crimea,  according  to 
Chenu,  of  81  amputations  of  the  thigh  at  the  upper  third,  37,  or  60  per 
cent.,  died ;  in  91  amputations  at  the  middle  third,  there  were  63  deaths, 
or  69  per  cent. ;  and  in  the  lower  third  there  were  101  cases  with  59 
deaths,  or  58.4  per  cent.  In  the  Italian  campaign  of  1859,  according  to 
the  same  authority,  there  were  46  cases  of  amputation  of  the  thigh  at 
the  upper  third,  with  43  deaths,  or  93  per  cent. ;  52  at  the  middle  t^hird, 
with  a  mortality  of  44,  or  84  per  cent. ;  and  43  at  the  lower  third,  with 
36  deaths,  or  83  per  cent.  Again,  among  21  amputations  of  the  humerus 
at  the  neck  in  the  French  army  in  the  Crimea,  the  mortality  was  9,  or 
43  per  cent.;  in  229  at  the  upper  third,  it  was  62,  or  27  per  cent.;  in 
145  at  the  middle  third  it  was  27,  or  18  per  cent. ;  and  in  55  at  the  lower 
third  it  was  6,  or  11  per  cent. 

Not  only  do  the  size  of  the  part  removed,  and  its  proximity  to  the 
trunk,  influence  materially  the  general  mortality  after  amputation  ;  but 
these  conditions  also  influence  the  particular  cause  of  death.  Thus,  after 
the  smaller  amputations,  as  of  a  toe,  for  instance,  death  occurs  only  in 
unhealthy  states  of  the  constitution,  from  the  occurrence  of  erysipelas,  or 
of  some  of  the  various  forms  of  diffuse  inflammation.  Death  after  the 
larger  amputations  more  frequently  results  from  causes  connected  with 
the  operation  itself,  as,  for  instance,  secondary  hemorrhage,  shock,  or 
exhaustion  by  the  abstraction  of  the  large  quantity  of  blood  contained 
in  the  limb,  as  well  as  by  that  lost  during  the  operation.  After  the 
removal  of  the  whole  limb,  as  in  the  case  of  amputation  at  the  hip-joint, 
it  is  possible  that  the  cause  suggested  by  Cox,  viz.,  the  removal  of  a 
limb  in  which  the  blood  undergoes  changes  of  importance  to  the  rest  of 
the  economy",  may  materially  affect  the  result. 

2.  The  Part  of  the  Bone  that  is  sawn  through  may  influence  the  result. 
Amputations  through  the  cancellous  ends  of  long  bones  are  less  danger¬ 
ous,  in  one  respect,  than  those  through  their  shafts,  in  consequence  of 
the  medullary  canal  not  being  opened  when  the  section  is  made  near  the 
articular  end ;  so  that  the  liability  of  diffuse  suppuration  of  this  cavity, 
and  of  consecutive  plilebitis  and  pyaemia,  is  diminished. 

3.  The  mortality  resulting  from  amputations  is  perhaps  more  directly 
influenced  by  whether  the  operation  is  done  for  Injury  or  Disease^  than 
by  any  other  cause,  being  far  greater  in  corresponding  linbs  after  injury 


MORTALITY  AFTER  AMPUTATION. 


55 


than  disease,  except  as  regards  amputation  of  the  forearm.  In  the 
following  table  ma}^  be  seen  the  results  of  307  consecutive  cases  of  am¬ 
putation  performed  at  University  College  Hospital  up  to  May,  1871. 

RESULTS  OF  AMPUTATION  IN  UNIVERSITY  COLLEGE  HOSPITAL. 


Amputation  for  Injury. 


SEAT  OF  AMPETATIOX. 

CASES. 

RECOVERIES. 

DEATHS. 

PERCENTAGE 
OF  DEATHS. 

Thigh 

• 

• 

39 

16 

23 

59.0 

Leg  and  foot  . 

• 

• 

44 

30 

14 

31.8 

Shoulder  and  arm  . 

• 

12 

7 

5 

41.6 

Forearm 

• 

• 

• 

8 

8 

0 

0 

Total  . 

. 

• 

• 

. 

103 

61 

42 

40.7 

Amputation  for  Disease. 


SEAT  OF  AMPCTTATION. 

CASES. 

RECOVERIES. 

DEATHS. 

PERCE.NTAGE 

OF  DEATHS. 

Thigh 

• 

86 

68 

18 

20.9 

Leg  and  foot  . 

74 

64 

10 

13.5 

Shoulder  and  arm  . 

• 

• 

• 

24 

16 

8 

33.3 

Forearm 

• 

• 

• 

20 

19 

1 

5.0 

Total  . 

• 

• 

• 

• 

204 

167 

37 

18.1 

Of  these  307  amputations,  66  occurred  in  the  Hospital  up  to  1841,  and 
are  reported  by  Potter  in  a  paper  published  in  the  Medico- Chirurgico.1 
Transactions  for  that  year.  They  were  performed  by  the  several  Sur- 
ojeons  of  the  Institution  at  that  time.  Of  the  remaininor  241,  41  were 
performed  by  Liston,  between  1841  and  his  death  in  1847  ;  5  by  his  im¬ 
mediate  successors;  and  195  b}"  the  author. 

Malijaio^ne’s  statistics  from  the  Parisian  hospitals  illustrate  this  matter 
in  an  equally  clear  point  of  view,  as  will  be  seen  in  the  following  tables. 


SEAT. 


Thigh 

Leg\ 

Foot 

x\rm 


Injury. 

Disease. 

CASES. 

DEATHS. 

PER  CENT. 

CA^ES. 

DEATHS. 

PER  CENT. 

46 

34 

74. 

153 

92 

60. 

79 

50 

63.3 

112 

55 

49. 

9 

6 

66.6 

29 

3 

10.3 

30 

17 

56.6 

61 

24 

60. 

Tlie  following  table  gives  the  result  of  numerous  cases  in  civil  practice, 
collected  from  various  sources.  (See  note,  page  53.) 


SEAT, 


Thigh 

o 

TiPo* 

Arm 

Forearm  . 


Injury. 

Disease. 

CASES. 

DEATHS. 

PER  CENT. 

CASES. 

DEATHS. 

PER  CENT. 

964 

576 

59.7 

1465 

477 

32.5 

771 

356 

46.1 

1281 

301 

23.5 

514 

180 

34.4 

250 

65 

26.0 

360 

38 

10.5 

151 

23 

15.9 

56 


AMPUTATIONS. 


The  shoch  inflicted  by  the  injury,  with  its  subsequent  evils,  appears  to 
be  one  of  the  principal  reasons  of  the  greater  frequency  of  the  mortality 
after  amputations  for  injury  than  after  those  for  disease.  After  ampu¬ 
tation  for  injur}^  also,  there  is  a  greater  liabilit}^  to  the  occurrence  of 
gangrene  of  the  stump,  and  pj’semia  and  its  secondary  elfects,  than  in 
the  case  of  the  removal  of  a  limb  for  disease  ;  in  which  the  principal 
causes  of  death  usually  appear  to  be  exhaustion,  and  the  supervention 
of  disease  of  the  lungs.  In  amputation  in  cases  of  disease,  it  will  be 
found  that  those  patients  do  best  in  whom  the  disease  is  most  chronic. 
This  is  especially  observable  in  cases  of  disease  of  bones  and  of  the 
joints. 

4.  The  Nature  of  the  Disease  for  which  the  amputation  is  performed 
influences  its  mortalit}".  Thus,  amputations  for  malignant  disease  are 
more  fatal  than  those  for  caries  of  bone  or  diseased  joints.  In  cases  of 
diseased  joint,  there  is  a  greater  tendency  to  recover  when  the  affection 
is  of  a  simple  than  when  it  is  of  a  tuberculous  nature.  Birkett  has 
pointed  out  that  disease  of  internal  organs,  often  of  the  same  nature  as 
that  for  which  the  operation  is  performed,  is  found  after  death  in  a  large 
proportion  of  patients  who  die  after  amputation.  When  suppurative 
disorganization  of  a  joint  is  very  acute,  amputation,  more  particular!}’' 
if  the  afiected  articulation  be  of  large  size,  as  the  knee,  is  attended  by 
very  unfavorable  results.  The  tendenc}^  to  pysemia  is  especially  strong 
in  such  cases,  the  blood  being  loaded  with  effete  materials,  the  products 
of  the  inflammatory  action,  which  are  specially  apt  to  run  into  suppura¬ 
tion,  both  in  it  and  in  the  tissues  generall3^  But  when  the  disease  has 
once  become  chronic,  the  precise  period  at  which  the  amputation  is  per¬ 
formed  exercises  but  little  influence  on  the  mortality,  provided  it  be  not 
deferred  to  too  late  a  stage,  when  the  patient’s  constitution  is  worn  out 
by  hectic. 

Amputations  of  expedienc}" — those  performed  for  the  convenience  of 
the  patient,  as  in  cases  of  talipes  or  ank3dosis,  but  not  necessary,  so  far 
as  life  is  concerned — are  especiall}"  fatal.  Bryant  has  shown  that,  at 
Gu3’’s  Hospital,  death  has  followed  in  40  per  cent,  of  these  amputations 
of  the  lower  extremity. 

5.  In  amputation  in  cases  of  injuiy  an  important  question  has  to  be 
determined,  viz.,  the  influence  exercised  by  the  Time  that  has  elapsed 
from  the  infliction  of  the  injuiy  to  the  performance  of  the  amputation. 
Not  onl}’  the  rate  of  mortalit}",  but  the  conditions  that  immediately 
occasion  the  fatal  event,  are  influenced  by  the  period  at  which  the  ope¬ 
ration  is  performed. 

Amputations  for  injuiy  are  commonl}"  divided  b}"  Surgeons  into  Pri¬ 
mary  and  Secondary ;  Vue,  primary  being  those  that  are  performed  during 
the  first  twent3"-four  or  thirty  hours,  before  aiy  inflammatoiy  action  in 
the  part  injured  has  taken  place.  By  secondary  amputations,  maiy  Sur¬ 
geons  mean  those  operations  that  are  practised  after  the  first  twent3^-four 
hours ;  whilst  others  again  restrict  the  term  to  those  that  are  done  after 
suppuration  has  been  set  up  in  the  limb,  calling  those  amputations  inter¬ 
mediate  that  are  performed  between  these  two  periods,  viz.,  from  the 
twent3^-fourth  hour  to  the  occurrence  of  suppuration,  and  which  conse- 
quentl}'  occup}'  a  veiy  extensive  range.  I  think,  however,  that  this  dis¬ 
tinction  is  somewhat  trivial,  and  not  very  easil}^  applied  in  practice ;  and 
that  it  is  better  to  include  under  the  term  secondary^  all  amputations 
performed  after  inflammatory  action  has  been  set  up  in  the  injured  part. 


PRIMARY  AND  SECONDARY  AMPUTATIONS. 


57 


KESULTS  OF  PEIMARY  AND  SECONDARY  AMPUTATIONS  IN  CASES  OF  INJURY, 

AT  UNIVERSITY  COLLEGE  HOSPITAL. 


SEAT. 

Primary. 

Secondary. 

CASES. 

DEATHS. 

CASES. 

DEATHS. 

Thigh . 

14 

8 

21 

14 

Leg  and  foot  ..... 

22 

8 

16 

3 

Shoulder  and  arm  .... 

6 

2 

5 

2 

Forearm . 

6 

0 

1 

0 

Total . 

48 

12 

43 

19 

The  subjoined  table  shows  the  relative  results  of  primary  and  secondary 
operations  in  civil  practice. 


Primary. 

Secondary. 

CASES. 

DEATHS. 

CASES. 

DEATHS. 

164 

Ill 

97 

51 

Lane  (Tables). 

19 

6 

14 

5 

Callender  (St.  Bartholomew’s). 

Thigh  . 

.  - 

24 

12 

17 

12 

Steele  (Guy’s  Hospital). 

10 

9 

21 

14 

London  Hospital. 

- 

18 

15 

7 

3 

Massachusetts  Hospital. 

306 

131 

104 

49 

Lane  (Tables). 

27 

8 

14 

5 

Callender  (St.  Bartholomew’s). 
Steele  (Guy’s  Hospital). 

Leg  .  . 

•  •  * 

38 

20 

15 

7 

17 

12 

8 

8 

London  Hospital. 

- 

17 

7 

9 

3 

Massachusetts  Hospital. 

199 

58 

48 

19 

Lane  (Tables). 

25 

1 

7 

3 

Callender  (St.  Bartholomew’s). 
Steele  (Guy’s  Hospital). 

Arm  .  . 

.  .  < 

24 

9 

5 

1 

16 

8 

7 

3 

London  Hospital. 

12 

3 

8 

6 

Massachusetts  Hospital. 

* 

153 

12 

21 

3 

Lane  (Tables). 

Forearm 

22 

1 

2 

1 

Callender  (St.  Bartholomew’s). 
Steele  (Guy’s  Hospital). 

•  •  * 

10 

3 

1 

1 

- 

5 

0 

3 

1 

London  Hospital. 

An  examination  of  the  preceding  Table  gives  the  following  general 
results. 


SEAT. 

Primary. 

Secondary. 

CASES. 

DEATHS. 

PER  CENT. 

CASES. 

DEATHS. 

PER  CENT. 

Thigh  .... 

235 

153 

65.1 

156 

85 

54.4 

Leg . 

405 

178 

43.9 

150 

72 

48.0 

Arm  .... 

276 

79 

28.6 

75 

32 

42.0 

Forearm  .... 

190 

16 

8.4 

27 

6 

22.2 

Total 

1106 

426 

38.5 

408 

195 

47.7 

58 


AMPUTATIONS. 


While  the  percentage  of  deaths  after  primary  amputation  of  the  thigh 
exceeds  that  after  secondary  amputation,  the  rate  of  mortality  in  ampu¬ 
tations  of  the  leg,  forearm,  and  arm  is  greater  after  the  secondary  than 
after  the  primary  operation,  especially  in  the  upper  limb.  Primary  ampu¬ 
tation  of  the  thigh  is,  indeed,  one  of  the  most  fatal  operations  in  surgery. 
Thus,  of  46  cases  of  primary  amputation  recorded  by  Malgaigne,  34 
perished ;  of  18  cases  in  the  Massachusetts  Hospital  at  Boston  during 
the  five  years  1863-1868,  15  died;  9  cases  out  of  10  died  at  the  London 
Hospital  during  the  years  1863-1866 ;  and  of  24  cases  recorded  by 
South,  Lawrie,  and  Peacock,  as  occurring  at  St.  Thomas’s  Hospital,  the 
Glasgow  Infirmary,  and  the  Edinburgh  Infirmary,  every  one  perished. 
The  danger  of  amputation  of  the  thigh  for  injury  is  increased  in  pro¬ 
portion  to  the  height  at  which  the  limb  is  severed.  It  is  least  in  those 
cases  where  the  operation  is  done  for  injury  of  the  leg  or  knee-joint,  and 
greatest  when  it  is  performed  for  compound  fracture  of  the  femur, 
recovery  from  which  is  very  rare.  This  excess  of  mortality  after  pri¬ 
mary  amputation  of  the  thigh  must  be  referred  mainly  to  the  intensity 
of  the  shock,  whether  produced  by  the  operation  itself,  or,  more  often, 
b}^  the  injury  which  has  rendered  its  performance  necessary.  The 
sudden  disturbance  of  the  balance  in  the  supply  of  blood,  caused  by  the 
removal  of  so  large  a  portion  of  the  body,  may  also  contribute  to  the 
danger.  In  primary  amputations  of  the  leg,  arm,  and  forearm,  however, 
the  influence  of  these  causes  is  relatively  less,  while  in  secondary  ampu¬ 
tations  of  these  parts,  as  well  as  of  the  thigh,  shock  is  much  less  intense. 
In  these,  the  chief  danger  arises  from  p3"8emia,  gangrene,  diffuse  inflam¬ 
mation,  secondary  hemorrhage,  and  all  those  morbid  conditions  that  are 
favored  by  defective  h^^gienic  circumstances,  and  which  appear  to  exer¬ 
cise  a  more  uniformly  unfavorable  influence  over  the  secondary  ampu¬ 
tations  than  shock  does  over  the  primary. 

In  military  practice,  secondaiy  amputation  is,  in  general,  more  fatal 
than  primary.  Thus,  Faure  saved  only  30  out  of  300  secondaiy  ampu¬ 
tations,  whilst  Larrey  saved  three-fourths  of  those  in  which  he  amputated 
primarily.  In  the  Peninsular  war,  the  mortality  after  secondary  ampu¬ 
tation  of  the  upper  extremity  was  twelve  times,  and  after  secondary 
amputation  of  the  lower  limb,  three  times,  as  great  as  after  primary 
amputation  of  these  parts.  In  the  British  army  in  the  Crimea,  from 
the  1st  of  April  to  the  close  of  the  war,  the  relative  rates  of  mortality 
per  cent,  after  primary  and  secondary  amputations  were  as  follows : 
after  primary  amputations  at  the  shoulder,  26  ;  of  the  arm.  It  ;  of  the 
forearm,  3 ;  of  the  thigh,  62 ;  of  the  leg,  30  ;  and  of  the  foot.  It :  after 
secondary  amputations  at  the  shoulder,  66  ;  of  the  arm,  31 ;  of  the  fore¬ 
arm,  28;  of  the  thigh,  80;  and  of  the  leg,  t6.  Or,  for  the  upper  ex¬ 
tremity,  the  whole  rate  of  deaths  after  primary  was  15,  against  41  after 
secondary  amputations  ;  whilst,  for  the  lower  extremity,  excluding  the 
foot,  it  was  46  for  the  primary,  against  18  per  cent,  for  the  secondary. 

In  the  American  army  during  the  w^ar  of  the  rebellion,  the  mortality 
after  primary  amputation  of  the  thigh  was  54.13  per  cent.;  and  after 
secondary  amputation  14.16.  In  the  French  arm}’  in  the  Crimea,  on  the 
other  hand,  the  mortality  after  primary  amputation  of  the  thigh  and 
arm — amounting  in  the  former  limb  to  above  90  per  cent. — was  greater 
than  that  after  the  secondary  operation. 

As  has  already  been  observed,  not  only  does  the  rate  of  mortality  differ 
in  primary  and  secondary  amputations,  but  also  the  cause  of  death. 
Primary  amputations  are  most  frequently  fatal  from  shock,  hemorrhage, 


AMPUTATIONS  OF  THE  HAND. 


59 


and  exhaustion,  although  death  from  pyaemia  and  secondary  diseases  of 
a  low  type  is  by  no  means  rare  in  these  cases.  Secondary  amputations 
for  injury  most  commonly  carry  off  the  patient  by  the  supervention  of 
diseases  of  a  low  type.  Amongst  these  secondary  affections  that  are, 
according  to  my  observation  at  the  University  College  Hospital,  of  most 
frequent  occurrence,  gangrene  of  the  stump  stands  in  the  first  place, 
especially  after  traumatic  amputation  of  the  thigh,  and  more  particu¬ 
larly  if  the  limb  have  been  in  a  similar  condition  before  the  ampu¬ 
tation.  Then,  again,  erysipelas,  phlebitis  with  pyaemia,  secondaiy 
hemorrhage,  and  some  of  the  low  forms  of  visceral  inflammation  or 
congestion,  as  pneumonia,  pleurisy,  and  diarrhoea,  often  produce  death. 
Pyaemia,  complicated  by  congestive  and  suppurative  pneumonia,  is  the 
most  frequent  cause  of  death  after  secondary  amputation  of  the  leg  and 
arm.  Secondary  hemorrhage  to  such  an  extent  as  to  prove  fatal  is  of 
very  rare  occurrence  ;  when  it  happens,  it  is  usually  associated  with  some 
diseased  state  of  the  blood  interfering  with  the  formation  of  a  plastic 
plug  in  the  artery. 

The  treatment  of  the  various  conditions  that  prove  fatal  after  ampu¬ 
tations  will  be  fully  discussed  in  other  parts  of  the  work. 


CHAPTER  III. 


SPECIAL  AMPUTATIONS. 


Amputations  of  the  Hand. — The  Fingers  often  require  amputation 
for  injury  or  disease,  more  especiallj''  as  the  result  of  bad  whitlow.  In 
many  cases  the  ungual  phalanx  becomes 
necrosed,  and  may  usually  most  readily  Fig.  9. 

be  removed  without  amputation,  by  ma¬ 
king  an  incision  through  the  pulp  of  the 
finger  and  then  extracting  the  diseased 
bone,  thus  saving  the  nail  and  pulp,  which 
will  form  an  excellent  end  to  the  finger  ; 
and,  if  the  operation  be  done  in  early 
childhood,  a  new  and  movable  phalanx 
may  form.  In  other  cases,  amputation 
will  be  required.  This  may  either  be 
done  by  cutting  into  the  joint  from  its 
dorsal  aspect  with  a  narrow-bladed  bis¬ 
toury,  running  across  it  lightl}^  touching 
the  lateral  liagaments,  and  making  the 
flap  from  the  palmar  aspect  (Fig.  9)  ;  or 
the  flap  may  conveniently  be  made  from  Amputation  of  Part  of  a  Finger  by  cutting 
the  palmar  surface  by  transfixion,  and  from  Above, 

then  cutting  across  the  joint  (Fig.  10).^ 

In  doing  this,  care  must  be  taken  to  avoid  cutting  too  far  backwards, 
and  so  mistaking  the  depression  above  the  head  of  the  second  phalanx 
for  the  articulation,  which  would  lead  to  a  little  embarrassment.  Some 
little  difficulty  is  occasionally  experienced  in  finding  the  joint,  and  Sur- 


^  For  the  Conservative  Surgery  of  the  Hand,  vide  chapter  xlviii. 


60 


SPECIAL  AMPUTATIONS. 


geons  have  endeavored  to  be  guided  to  it  by  attention  to  the  folds  in  the 
integument  covering  it ;  but  in  these  there  is  no  consistency,  and  no  cor¬ 
relation  exists  between  the  joint  and  these  folds  in  the  skin.  When  the 
amputation  is  performed  from  the  dorsal  aspect,  the  finger  should  be 


Fig.  10. 


Amputatiou  of  a  Finger.  Cutting  the  Flap  by  Transfixion. 


flexed,  when  the  joint  will  be  found  immediately  under  the  apex  of  the 
triangle  formed  by  the  phalanges.  In  operating  from  the  palmar  aspect, 
the  finger  should  be  forcibly  extended  as  soon  as  the  flap  is  made,  when, 
if  the  knife  be  applied  to  the  lateral  ligaments,  the  synovial  surface  will 
show  itself. 

Amputation  is  performed  between  the  proximal  and  second  phalanges 
in  the  same  way ;  but,  as  a  general  rule,  it  should  not  be  done  here ; 
because,  as  no  flexor  tendon  is  attached  to  the  proximal  phalanx,  it  is 
apt  to  remain  permanently  extended,  and  a  good  deal  in  the  patient’s 
way.  In  the  case  of  the  index  finger,  however,  it  will  be  better  to  leave 
the  proximal  phalanx,  the  stump  of  which  forms  an  useful  opponent  to 
the  thumb. 

Amputation  is  frequently  required  at  the  3Ietacarpo-'plialangeal  Ar¬ 
ticulation.  Here  it  may  be  done  in  two  ways  :  either  by  lateral  flaps,  or 
by  the  oval  method.  If  by  lateral  Jiaps^  the  adjoining  fingers  should 
be  well  separated  from  the  one  about  to  be  removed  b}^  an  assistant, 
who  grasps  the  hand  so  as  to  put  the  integument  on  the  dorsum  upon 
the  stretch  (Fig.  11).  The  point  of  a  bistoury  is  then  entered  about 
three-quarters  of  an  inch  above  the  head  of  the  metacarpal  bone  ;  it  is 
then  carried  forwards  to  a  point  opposite  the  interdigital  web,  drawn 
across  the  side  of  the  finger,  and  then  carried  a  little  way  into  the  palm. 
This  same  process  is  performed  upon  the  opposite  side,  the  flaps  are  dis¬ 
sected  down  by  a  few  touches  of  the  knife,  the  extensor  tendon  is  divided, 
the  joint  opened,  and  disarticulation  performed.  The  oval  method.,  which 
I  think  is  the  best,  as  it  does  not  wound  the  palm,  consists  in  entering 


AMPUTATION  OF  THE  FINGEKS. 


61 


the  bistoury  at  the  same  point  as  in  the  last  case,  carrying  it  as  far  as 
the  web,  drawing  it  across  the  palmar  aspect  of  the  finger,  and  then 
obliquely  baekw'ards  to  join  the  starting  point  of  the  incision.  By  a 
few  touches  of  the  point  of  the  knife  the  oval  flap  is  turned  back,  and 
the  articulation  opened.  As  a  general  rule,  it  is  better  to  remove  the 
head  of  the  metacarpal  bone,  together  with  the  finger ;  as  otherwise  a 
wide  gap  will  be  left  in  the  situation  of  the  finger  that  has  been  ampu- 

Fig. 11. 


Amputation  of  a  Finger.  Eemoving  the  Head  of  the  Metacarpal  Bone, 


tated,  and  much  deformity  of  the  hand  will  result.  This  may  be  done 
by  cutting  the  metacarpal  bone  across  beyond  its  head  with  bone-forceps 
in  a  transverse  direction,  if  it  be  either  the  middle  or  the  ring  finger  that 
is  removed  (Fig.  11).  If  it  be  the  index  or  the  little  finger,  the  bone 
should  be  cut  obliquely  from  without  inwards,  so  as  to  shape  it  to  the 
tapering  form  of  the  hand  (Fig.  12).  If  it  be  cut  directly  across,  an  ugly 
and  inconvenient  square  protuberance,  liable  to  constant  injury,  will  be 
left.  When,  however,  the  patient’s  employment  is  one  in  which  great 


62 


SPECIAL  AMPUTATIONS. 


strength  and  breadth  of  hand  are  required,  and  where  appearance  is  of 
little  consequence,  the  head  of  the  bone  may  advantageously  remain. 


Amputation  of  tlie  Index  Finger.  Removing  the  Head  of  the  Metacarpal  Bone. 


The  after-treatment  of  these  cases  is  extremely  simple.  The  hand 
should  be  put  upon  a  splint,  the  wound  covered  with  a  piece  of  water- 


Results  of  Amputation  above  Metacarpo-Phalangeal  Articulation  in  Middle,  Index,  and  Ring  Fingers. 


dressing,  and  the  ends  of  the  fingers,  with  small  pieces  of  lint  interposed, 
tied  together  by  means  of  a  tape,  care  being  taken,  however,  that  they 


AMPUTATION  OF  THE  THUMB. 


63 


do  not  overlap.  The  shaft  of  the  metacarpal  hone  that  is  left  -will 
sfradnally  atrophy,  and  thus  a  very  taper  and  shapely  hand  eventually  be 
left  (Figs.  13,  14,  and  15). 

In  disease  or  injury  of  the  Thumb  as  little  as  possible  should  be 
removed  by  amputation ;  for,  if  even  but  a  very  short  stump  of  the 
metacarpal  bone  be  left,  it  will  serve  as  an  useful  opponent  for  the  other 
fingers.  When  the  whole  thumb  requires  amputation,  it  may  most  con¬ 
veniently  be  removed  b}^  Liston’s  method.  The  mode  of  proceeding 
must  vary  according  to  the  side  operated  on.  When  the  left  thumb 
requires  amputation,  the  point  of  a  long  narrow  bistouiy  should  be 
introduced  well  on  the  palmar  aspect  of  the  carpo-metacarpal  articula¬ 
tion,  carried  over  this, 

which  it  opens  (Fig.  16),  Fig.  16. 

and  the  dorsum  of  the 
hand  as  far  as  the  web  of 
the  index  finger;  the  point 
of  the  knife  should  then 
be  pushed  downwards 
through  the  ball  of  the 
thumb,  transfixing  this, 
and  issuing  where  the  in¬ 
cision  commenced.  It  is 
next  made  to  cut  out¬ 
wards,  keeping  close  to 
the  metacarpal  bone, 
which  is  readily  twisted 
out,  the  remaining  at¬ 
tachment  being  separated 
by  a  few  touches  of  the 
knife.  An  oval  incision 
will  be  left,  which  comes 
together  closely  by  a  nar¬ 
row  line  of  cicatrix.  In 
amputating  the  right 
thumb,  it  will  be  neces¬ 
sary  for  the  Surgeon,  if 
he  adopts  the  method  just 

described,  either  to  use  Amputation  of  the  Left  Thumb  and  Metacarpal  Bone, 

his  left  hand,  or  to  cross 

his  hands  in  an  awkward  manner.  In  order  to  avoid  doing  this,  he  may 
reverse  the  steps  of  the  operation  with  advantage;  first  transfixing  the 
ball,  and  making  the  anterior  flap,  then  cutting  over  the  dorsum,  opening 
the  joint,  and  turning  out  the  bone  (Fig.  II).  Fig.  18  shows  the  hand 
after  amputation  of  the  thumb. 

.The  Metacarpal  Bones,  with  or  without  the  fingers  supported  by 
them,  occasionally  require  removal  for  disease  or  injury.  For  these 
operations,  which  are  not  of  a  veiy  regular  kind,  it  is  difficult  to  lay 
down  definite  rules  ;  in  performing  them,  care  should  be  taken  to  make 
good  square  flaps  of  sufficient  size,  but  to  avoid  cutting  into  the  palm  if 
possible.  It  is  well  not  to  disarticulate  the  lower  end  of  the  bone,  so  as 
to  open  the  wrist-joint,  but  rather  to  cut  it  off  with  bone-forceps  a  little 
above  this.  In  injuries  from  the  explosion  of  powder-flasks  or  gun- 
barrels,  when  the  hand  is  much  shattered,  it  is  of  great  consequence  to 
avoid  cutting  up  the  palm  to  too  great  an  extent ;  and  it  is  well  in  these 
cases  to  save  a  finger  if  possible,  which  will  be  of  more  use  to  the  patient 


64 


SPECIAL  AMPTJTATIOlSrS. 


than  any  artificial  limb,  however  ingeniously  constructed  (Figs.  19  and 
20).  When  only  one  finger  is  left,  as  the  index  or  little  finger,  with 


Fig.  17. 


Amputation  of  Right  Thumb  by  Transfixion.  Cutting  the  Anterior  Flap. 


the  thumb,  in  cases  of  partial  amputation  of  the  hand  after  injury  or 
for  disease,  the  digit  that  remains  not  only  becomes  more  mobile  than 
formerly,  but  greatl}^  increased  in  size  and  much  stronger,  so  that  its 
utility  is  materially  augmented. 


Fig. 


18. 


Result  of  Amputation  of  the 
Thumb. 


Hand  after  Amputation  of  Metacarpal 
Bones  and  First  Two  Fingers. 


Hand  after  removal  of  Meta¬ 
carpal  Bones  and  Three  Fin¬ 
gers,  leaving  Thumb  and  Little 
Finger. 


The  mortality  after  amputation  of  the  fingers  and  metacarpal  bones  is 
very  trifling.  Should  death  unfortunately  occur  after  such  a  slight 


AMPUTATIONS  OF  THE  AEM. 


65 


operation,  it  would  probably  be  by  the  accidental  occurrence  of  some 
general  disease,  such  as  erysipelas,  pyrnmia,  or  tetanus,  to  which  every 
wound  renders  a  patient  liable. 

Amputation  at  the  Wrist  is  not  veiy  often  required.  In  performing 
disarticulation  at  this  joint,  its  peculiar  shape  with  the  convexity  look¬ 
ing  upwards  must  be  borne  in  mind. 

The  integuments  being  well  re-  Fig.  21. 

tracted,  an  arched  incision  should 
be  made  from  one  styloid  process 
to  the  other,  across  the  back  of  the 
joint,  with  its  convexity  looking 
forwards  (Fig.  21).  The  articulation 
having  been  opened  and  the  lateral 
ligaments  divided,  the  knife  is  car¬ 
ried  forwards  so  as  to  make  a  well- 
rounded  flap  from  the  palmar  sur¬ 
face  ;  in  doing  this,  care  must  be 
taken  not  to  cut  against  the  pisiform 
bone,  which  projects  a  good  deal 
beyond  the  other  carpal  bones. 

Amputations  of  the  Arm. — 

Amputation  of  the  Forearm  is  not 

unfrequently  required  for  disease  or  Amputatioa  at  the  Wrist, 

injury  of  the  wrist  or  hand.  In 

performing  this  operation,  as  long  a  stump  should  be  left  as  possible,  so 
as  to  give  the  patient  more  power  over  any  artificial  limb  that  may  be 
fitted  to  it.  The  flaps  should  be  about  a  couple  of  inches  in  length, 
and  well  rounded,  the  hand  being  placed  in  a  mid-state  between  pronation 
and  supination.  The  dorsal  flap 
is  best  made  by  cutting  from  with¬ 
out  inwards  ;  the  line  of  incision 
commences  just  at  the  palmar 
aspect  of  the  ulna,  is  carried  for¬ 
wards  for  a  little  distance  parallel 
to  this  bone,  and  then  across  the 
back  of  the  arm  in  a  slightly 
curved  manner,  until  it  reaches 
the  palmar  aspect  of  the  radius  ; 
it  then  passes  along  this  until  it 
reaches  a  point  opposite  to  that 
at  which  it  commenced,  and  the 
flap  thus  made  is  dissected  back. 

The  palmer  flap  is  next  made  by 
transfixion  (Fig.  22).  As  soon 
as  it  is  cut,  the  bones  are  cleared 
b}’  a  couple  of  sweeps  of  the 
knife,  and  the  interosseous  mem¬ 
brane  is  divided ;  the}^  are  then 
sawn  together.  The  vessels  are 
cut  long  at  the  end  and  on  each 
side  of  the  palmar  flap. 

Amputation  of  the  Arm  is  most  readily  performed  by  lateral  flaps 
made  by  transfixion  from  before  backwards ;  the  bone  is  then  well  cleared 
by  a  couple  of  sweeps  of  the  knife,  and  sawn  across.  In  clearing  the 
bone,  care  must  be  taken  fairly  to  divide  the  musculo-spiral  nerve  by  a 


Fig.  22. 


Amputation  of  the  Forearm.  Transfixion  of  the 
Anterior  Flap. 


VOL.  I. — 5 


66 


SPECIAL  AMPUTATIONS. 


firm  sweep  of  the  knife  round  the  back  of  the  bone  (Fig.  23),  if  the  am¬ 
putation  be  performed  in  that  part  of  the  arm  where  the  nerve  winds 
round  the  humerus.  If  the  limb  be  veiy  muscular,  skin-fiaps  and  circu¬ 
lar  section  of  the  muscles  will  probabl}'  give  the  best  result. 

Fig.  23. 


Amputation  of  the  Arm.  Clearing  the  Bone 


Amputation  at  the  Shoulder-joint  ma}'  be  required  for  iujuiy  of 
the  arm  or  for  disease  of  the  humerus  ;  in  the  first  case  it  is  best  performed 
by  transfixion  ;  in  the  other,  b}'  cutting  from  without  inwards.  The  sub¬ 
clavian  artery  should  be  compressed  as  it  passes  over  the  first  rib  ; 
though,  if  the  assistant  be  steady  and  well  acquainted  wdth  his  duties, 
this  may  be  dispensed  with. 

In  operating  hj  transfixion,  a  long  narrow-bladed  knife  should  be  used. 
One  assistant  must  have  charge  of  the  limb;  another  should  raise  the 
flap;  and  a  third  must  follow  the  knife  as  it  cuts  behind  the  humerus, 
and  grasp  the.  inner  flap  with  the  axillary  arteiy,  so  as  to  prevent  hemor¬ 
rhage  from  this  vessel.  An  assistant  holding  the  arm  away  from  the 
bod}’,  so  as  to  relax  the  deltoid  somewhat,  the  knife,  instead  of  being 
entered  b}’  a  puncture,  should  make  a  small  cross-cut,  about  an  inch  in 
extent,  at  the  point  at  which  transfixion  is  to  be  made,  so  as  to  prevent 
that  jagging  of  the  integuments  by  the  heel  of  the  instrument  which 
would  otherwise  occur.  If  the  operation  be  on  the  right  side,  the  Sur¬ 
geon  stands  before  the  patient,  and  the  point  of  the  knife  should  be 
entered  about  an  inch  in  front  of  the  acromion,  or  midway  between  the 
acromion  and  the  coracoid  process  (Fig  24) ;  and  being  carried  directly 
across  the  joint  and  capsule,  should  pass  out  at  the  posterior  border  of 
the  axilla.  If  on  the  left  side,  the  Surgeon  stands  behind,  and  the  point 
of  the  knife  must  be  entered  well  behind  the  spine  of  the  scapula,  at  the 


AMPUTATION  AT  THE  SHOULDER- JOINT. 


67 


posterior  of  the  axilla,  carried  across  the  anterior  aspect  of  the  joint, 
and  brought  out  to  the  innner  side  of  the  caracoid  process.  In  either 
case,  the  large  flap  containing  the  deltoid  muscle  must  then  be  cut  b}'  a 
sweep  of  the  knife  downwards,  and,  as  soon  as  made,  raised  by  another 
assistant.  The  heel  of  the  knife  is  now  to  be  laid  on  the  head  of  the 

Fig.  24. 


Amputation  at  the  Shoulder-joint  by  Transfixion. 


bone,  the  capsule  of  the  joint  cut  across,  and  the  attachments  of  the 
muscles  to  the  tuberosity  divided.  In  order  to  facilitate  this  part  of  the 
operation,  it  is  generally'  recommended  that  the  arm  should  be  carried 
forcibl}"  inwards  across  the  chest.  This  may  readily  be  done  in  the  dis¬ 
secting-room,  or  in  actual  practice  where  the  limb  is  removed  for  disease 
of  the  humerus,  the  limb  being  entire ;  but  in  the  case  of  comminuted 
fracture  of  the  humerus,  with  extensive  laceration  of  soft  parts,  it  is 
useless  to  attempt  this  manoeuvre.  In  cases  of  this  kind,  the  head  and 
upper  end  of  the  humerus  being  broken  oflT  from  the  shaft,  the  lever-like 
action  of  the  bone  cannot  be  put  in  force,  and  it  is  sometimes  not  such 
an  easy  matter  as  might  at  first  appear,  to  detach  its  head  from  the 
glenoid  cavity.  In  order  to  do  this,  I  have  in  cases  of  comminuted 
fracture  of  the  humerus,  in  which  I  was  amputating  at  the  shoulder-joint, 
found  it  necessaiy,  after  opening  the  capsule,  to  seize  hold  of  the  upper 
fragment  and  to  draw  it  forcibly  downwards  and  inwards  b}^  inserting 
the  fingers  between  the  head  and  the  glenoid  cavity,  in  order  to  divide 
the  muscles  into  it.  After  the  head  of  the  bone  has  been  turned  out  of 
the  glenoid  cavit}',  the  knife  must  be  passed  behind  it,  and  carried  down 
for  a  distance  of  about  three  inches  close  to  the  bone  at  its  inner  side 
(Fig.  25).  The  Surgeon  then  cuts  across  the  soft  parts,  so  as  to  form 
the  inner  flap.  In  doing  this,  the  assistant,  to  whom  this  part  is  entrusted. 


68 


SPECIAL  AMPUTATION’S. 


must  follow  the  knife  with  his  hands,  grasping  firmly  the  whole  thickness 
of  the  inner  flap,  so  as  to  compress  the  axillary  artery,  and  thus  prevent 


Amputation  at  the  Shouldei-joint.  Opening  the  Capsule,  and  making  Inner  Flap. 

the  occurrence  of  hemorrhage  (Fig.  26).  The  Surgeon  should  not  cut 
the  flap  across  until  the  assistan^tells  him  that  he  holds  the  vessel  firmly, 
and  then  he  must  he  cautious  not  to  injure  his  assistant’s  fingers.  The 
artery  will  he  found  to  he  cut  long  in  the  middle  of  the  posterior  flap, 
and  a  few  smaller  hranches  may  he  required  to  he  tied  at  its  inner  angle, 
and  in  the  deltoid.  The  stump  after  it  is  healed  will  present  the  appear¬ 
ance  shown  in  Fig.  2t. 

Amputation  at  Shoulder  by  Oval  Method. — In  cases  where,  from  the 
state  of  the  hone,  the  manipulations  necessary  for  amputation  h3’’  trans¬ 
fixion  are  impossible,  the  method  originally  invented  hy  Larre^^,  or  some 
modification  of  it,  must  he  adopted.  Larrey  commenced  his  operation  hy 
a  vertical  incision  down  to  the  hone,  about  two  inches  in  length,  com¬ 
mencing  immediately  below  the  acromion  process.  From  the  end  of  this 
he  made  a  curved  incision  on  each  side,  reaching  to  the  corresponding 
fold  of  the  axilla.  The  two  flaps  thus  formed  were  dissected  up,  and 
the  head  of  the  hone  disarticulated.  The  knife  was  then  passed  inter¬ 
nally  to  the  head  of  the  hone,  and  carried  downwards,  while  an  assistant 
followed  it  with  his  hands  to  compress  the  axillary  artery.  The  opera¬ 
tion  was  completed  hy  dividing  the  tissues  in  the  axilla,  between  the 
ends  of  the  two  curved  incisions  previously  made  to  its  borders. 

The  most  important  modification  of  this  method  is  that  of  Spence, 
which  is  specially  adapted  for  gunshot  wounds  of  the  upper  end  of  the 
humerus.  It  consists  in  carrying  the  vertical  incision  further  forwards. 


Amputation  at  the  Shoulder-joint.  Holding  Vessels  in  the  Inner  Flap. 


expose  the  tendon  of  the  long  head  of  the  Fio-.  27. 

biceps  lying  parallel  to  it  at  its  bottom. 

This  maybe  turned  on  one  side,  and  the  joint 
opened  and  examined  ;  and  if  from  the  state 
of  the  parts  it  be  still  considered  necessary 
to  amputate,  the  operation  is  completed  by 
making  an  oval  incision  tlirough  the  skin 
from  the  end  of  the  orio-inal  cut,  taking;  care 
not  to  go  so  deep]}'-  on  the  inner  side  as  to 
wound  the  vessels.  The  outer  flap  is  then 
dissected  up,  so  as  to  enable  the  Surgeon  to 
get  his  knife  internal  to  the  head  of  the  bone, 
between  it  and  the  axillary  artery  (Fig.  28). 

The  assistant  follows  the  knife  with  his  liands, 
and  grasps  the  vessels,  and  the  operation  is 
finished  b}^  dividing  the  tissues  left  uncut  at 
the  inner  side. 

In  those  cases  in  which  this  operation  re¬ 
quires  to  be  performed  for  disease,  especially 
for  tumor  of  the  humurus,  by  which  the  soft 
parts  are  thinned  or  condensed,  it  may  very 
conveniently  be  done  by  making  the  anterior 
flap  b}'  dissecting  it  up  from  without  in¬ 
wards  ;  using  of  course  for  this  purpose  a  short  knife  ;  a  broad  bistoury 
is  most  convenient.  The  joint  is  then  opened,  and  the  posterior  flap 


Stump  after  Auputation  at  the 
Shoulder-joint. 


AMPUTATION  AT  THE  SHOULDEE- JOINT.  69 


and  commencing  it  just  externall}"  to  and  below  the  tip  of  the  coracoid 
process,  as  in  excision  of  the  shoulder-joint.  The  incision  ought  to 


Fig.  26. 


70 


SPECIAL  AMPUTATIONS. 


formed  in  the  usual  way.  In  this  way  I  have  easily  performed  amputa¬ 
tion  at  the  shoulder-joint  for  large  tumors  of  the  head  of  the  humerus. 


Fig.  28. 


Amputation  at  Shoulder  by  Spence’s  Method. 


General  Results  of  Amputations  of  the  Uptper  Limb. — Amputations  of 
the  upper  extremit}^,  even  for  injury,  are  extremely  successful.  In  the 
Crimea,  amputations  of  the  forearm  were  fatal  in  the  ratio  of  5,  and 
those  of  the  arm  of  24.5  per  cent.  The  table  at  p.  55,  in  the  last  chapter, 
gives  a  mortality  of  34.4  per.  cent,  for  traumatic  amputations  of  the 
upper  arm,  and  of  10.5  per  cent,  for  amputation  of  the  forearm.  At 
Guy’s  Hospital,  Bryant  states  that  traumatic  amputations  of  the  fore¬ 
arm  were  fatal  in  the  ratio  of  16,  and  those  of  the  upper  arm  of  22  per 
cent.  At  University  College,  in  Liston’s  and  my  practice,  of  12  trau¬ 
matic  amputations  of  the  upper  arm,  there  were  5  deaths ;  whilst  of  8 
in  which  the  forearm  was  removed,  all  recovered.  The  cause  of  death  is 
usually  pyaemia,  erysipelas,  or  congestive  pneumonia. 

Amputations  of  the  forearm  and  arm  for  disease,  more  particularly  for 
strumous  affections  of  the  bones  and  joints,  are  veiy  successful  ope¬ 
rations.  When  they  are  done  for  malignant  disease,  the  risk  is  greater. 
In  the  table  already  referred  to,  the  mortality  after  amputation  of  the  arm 
for  diseases  is  26  per  cent.,  and  of  the  forearm  15.9  per  cent. 

Amputation  at  the  shoulder-joint  for  injury,  although  necessarily  more 
fatal,  is  very  successful  for  so  severe  a  procedure.  In  46  recorded  cases 
in  civil  practice,  there  have  been  26  deaths,  or  56.5  per  cent.,  while  of 
601  cases  in  military  surgery,  294,  or  48.4  per  cent.,  have  died.  In  the 
French  arra}^  in  the  Crimea,  of  222  cases,  137  died,  or  61.7  per  cent.  ; 
while  in  the  English  army  during  the  same  war,  the  mortality  was  only 


AMPUTATIONS  OF  THE  FOOT. 


71 


35  per  cent.,  and  in  the  war  of  the  American  rebellion,  it  was  39.2  per 
cent.  At  University  College  Hospital,  I  have  done  the  operation  6  times 
with  1  fatal  result.  When  this  operation  proves  fatal,  the  patient  usually 
sinks  from  exhaustion,  or  is  carried  off  by  the  extension  of  erysipelas  or 
gangrene  to  the  stump  and  trunk. 

Amputation  at  the  shoulder-joint  for  disease  of  the  humerus  is  a  very 
successful  procedure,  considering  the  size  of  the  part  removed,  and  its 
proximity  to  the  trunk.  In  23  cases  there  have  been  5  deaths. 

Amputations  of  the  Foot. — The  Phalanges  of  the  Toes  seldom 
require  amputation :  when  they  do,  thej^  may  be  removed  in  the  same 
wa}^  as  the  corresponding  parts  in  the  hand — by  the 
formation  of  a  flap  on  the  plantar  surface,  either  by  Fig.  29. 

cutting  from  above  downwards,  or  by  transfixion. 

In  removing  a  bone  at  the  Metatar so-phalangeal 
Articulation^  the  oval  method  should  always  be 
practised,  so  that  the  sole  of  the  foot  may  not  be 
cut  into.  In  doing  this  it  must  be  remembered 
that  the  articulation  is  situated  considerably  above 
the  web  of  the  toes,  and  the  incision  must  there¬ 
fore  be  commenced  proportionately  far  backwards 
(Fig.  29).  As  a  general  rule,  it  will  be  found  that 
the  articulation  is  about  the  same  distance  above 
the  web  as  the  point  of  the  toe  is  below  it. 

The  Metatarsal  Bone  of  the  Great  Toe  occasion¬ 
ally  requires  removal  in  whole  or  in  part.  The 
whole  of  the  bone  may  be  readily  removed  by  one  incision  in  Amputation  of  a 
of  two  methods:  1,  by  the  flap;  2,  by  an  oval  Toe. 

amputation. 

1.  The  Flap  Amputation  is  done  as  follows.  The  point  of  a  strong 
broad  bistoury  is  entered  on  the  dorsum  of  the  foot  over  the  interspace 
between  the  first  and  second  meta¬ 
tarsal  bones,  as  far  back  as  possible  ; 
it  is  then  carried  forwards  upon  the 
ball  of  the  great  toe,  to  a  point  op¬ 
posite  to  the  web  between  the  toes, 
and  thence  made  to  sink  into  the 
sole  of  the  foot  in  a  line  parallel 
with  the  outer  margin  of  the  bone ; 
the  flap  thus  formed  is  dissected 
back,  its  plantar  aspect  being  kept 
as  thick  and  flesh}^  as  possible  (Fig. 

30).  The  Surgeon  next  passes  the 
knife  between  the  first  and  second 
metatarsal  bones,  and  cuts  directly 
forwards  through  the  centre  of  the 
angle  between  the  great  and  the 
second  toes.  In  doing  this,  care 
must  be  taken  that  the  edge  of  the 
knife  is  not  directed  too  much  towards  the  metatarsal  bone  of  the  great 


Fig.  30. 


Removal  of  Metatarsal  Bone  of  Great  Toe:  Flap 
formed  :  Joint  being  opened. 


toe,  lest  it  hitch  against  one  of  the  sesamoid  bones.  The  Surgeon  next 
seizes  the  extremity  of  the  toe,  and,  passing  it  well  inwards,  passes  the 
point  of  the  bistouiy  deeply  into  the  angle  of  the  wound  (Fig.  31),  where, 
by  the  division  of  some  tendinous  and  ligamentous  fibres  that  constitute 
the  ke}^  of  the  joint,  he  opens  the  articulation,  and  detaches  the  bone  by 
lightl}’’  touching  its  ligamentous  attachments.  By  keeping  the  edge  of 


72 


SPECIAL  AMPUTATIONS. 


the  knife  well  against  the  side  of  the  bone,  he  may  avoid  wounding  the 
dorsal  arter^^of  the  foot,  the  bleeding  from  w'hich  would  be  troublesome. 
When  the  bone  is  to  be  partially  removed,  the  operation  must  be  per- 


Fig.  31. 


formed  in  the  same  way ;  the  incisions,  however,  not  being  carried  so  far 
backwards. 

2.  In  Amputation  by  the  Oval  Method^  the  point  of  the  bistoury  is 
entered  in  the  dorsum  of  the  foot,  just  behind  the  tarsal  end  of  the  bone. 
An  incision  is  carried  up  to  the  digital  interspace,  and  is  made  to  circle 
around  the  base  of  the  first  phalanx,  so  as  to  join  the  first  line  of  incision 
on  the  dorsum.  The  soft  structures  on  the  inner  side  are  then  dissected 
down,  the  knife  being  kept  close  to  the  bone.  The  same  process  is  carried 
on  at  the  outer  side,  the  blade  made  to  sweep  under  the  bone  from  without 
inward,  and  the  tarsal  joint  opened  as  described  in  the  flap  operation. 

This  process  has  the  advantage  of  leaving  the  sole  uninjured.  It  has 
the  disadvantage  of  favoring  an  accumulation  of  sanies  and  pus  at  the 
deeper  part  of  the  wound. 

3.  If  the  disease  be  limited  to  the  anterior  part,  the  shaft  of  the  bone 
should  be  cut  across  with  a  pair  of  bone-nippers,  and  its  head  left ;  for, 
as  this  gives  insertion  to  the  peroneus  longus,  its  removal  will  materially 
weaken  the  foot. 

The  Metatarsal  Bone  of  the  Little  Toe  may  conveniently  be  removed 
by  an  oval  incision,  so  as  to  avoid  wounding  the  sole  of  the  foot.  This 
is  best  done  by  entering  the  point  of  the  knife  just  behind  the  tubercle 

of  the  bone,  carrying  it 
forwards  and  inwards  in 
the  line  of  its  articula¬ 
tion  with  the  cuboid,  to 
the  centre  of  the  fourth 
digital  interspace,  and 
thence  forwards  to  the 
web  of  the  toe  ;  the  knife 
is  next  carried  around  the 
plantar  surface  of  this,  the 
incision  beins:  continued 
obliquely  into  that  which 
has  been  made  on  the  dor- 


Fig.  32. 


Kemoval  of  Metatarsal  Bone  of  Little  Toe  :  Flap  formed  : 
Bone  being  cleared. 


AMPUTATION  OF  THE  TOES 


73 


sum  of  the  foot  (Fig.  32).  The  small  flap  thus  formed  is  well  dissected 
down,  the  knife  passed  around  the  under  surface  of  the  bone,  and  the 
joint  opened  by  the  toe  being  forcibly  drawn  outwards,  and  its  liga¬ 
mentous  connection  lightly  divided. 

The  whole  of  the  Metatarsal  Bones  may  be  removed  from  the  tarsal  by 
the  operation  originally  planned  and  executed  b}’’  Hey.  This  consists  in 
first  of  all  making  a  large  convex  flap  in  the  sole  of  the  foot,  one  horn 
of  which  commences  at  the  tubercle  of  the  fifth  metatarsal  bone,  whilst 
the  other  terminates  at  that  of  the  first,  or  rather  opposite  the  projection 
of  the  scaphoid.  A  small  flap  is  then  made  on  the  dorsum  of  the  foot, 
and  the  articulations  are  exposed.  These  must  then  be  opened  with 
some  care,  as  they  are  veiy  irregular  (Fig.  33)  ;  the  second  metatarsal 
bone,  especially,  being  sunk  into  a  kind  of  pit  in  the  middle  cuneiform, 
and  the  articulation  of  the  fifth  with  the  cuboid  being  very  oblique. 
This  operation  is  seldom  practised,  disease  being  rarely  limited  to  the 
metatarsal  bones,  but  usually  implicating  the  joints  as  well.  Their  dis¬ 
articulation  also  from  the  tarsus  is  very  troublesome,  on  account  of  the 
irregularity  of  the  line  of  articulation  ;  hence  it  is  better  to  saw  through 
the  metatarsus  just  in  front  of  the  tarsal  articulations,  than  to  attempt 
to  disjoint  the  bones.  A  combination  of  these  two  procedures  may  some¬ 
times  be  advantageously  adopted.  In  one  of  those  severe  crushes  of  the 
anterior  part  of  the  foot,  that  are  not  unfrequently  the  result  of  railway 
injury,  and  in  which  the  bones  and  soft  parts  are  irregular!}^  crushed 
and  torn,  I  made  a  very  excellent  stump  by  disarticulating  the  first  and 
the  fifth  metatarsal  bones,  and  sawing  across  the  three  middle  ones  almost 
an  inch  anterior  to  their  articulations  with  the  tarsus. 


Fig.  34. 


Fig.  33. 


Line  of  Hey’s  Operation. 


Line  of  Chopart’s  Operation. 


Amputation  through  the  Tarsus  may  conveniently  be  performed  by 
Chopart’s  operation,  which  consists  in  disarticulation  in  the  line  between 
the  os  calcis  and  astragalus  behind,  and  the  cuboid  and  scaphoid  in  front 
(Fig.  34).  This  operation  may  be  performed  either  by  first  making  the 
flap  from  the  sole  of  the  foot,  and  then  disarticulating  (Fig.  35)  ;  or,  the 
joints  having  been  cut  through  from  the  dorsum,  the  flap  may  afterwards 
be  made  (Fig.  36).  I  prefer  the  first  plan,  as  it  leaves  a  correctly 
fashioned  flap. 

In  operating  on  the  left  foot,  the  knife,  a  stout  bistoury,  should  be 
entered  well  behind  the  tubercle  of  the  scaphoid,  and  carried  forwards 
for  at  least  three  inches,  to  about  the  head  of  the  metatarsal  bone  of  the 
great  toe,  then  right  across  the  sole,  and  down  the  outer  side  of  the  foot. 


74 


SPECIAL  AMPUTATIONS. 


as  far  as  half  an  inch  behind  the  metatarsal  bone.  On  the  right  foot  this 
line  of  incision  is  reversed,  by  the  knife  being  entered  half  an  inch  behind 


Fig.  35. 


Chopart’s  Operation  ;  Flap  formed 
before  Disarticulation. 


Fig.  3G. 


Chopart’s  Operation  :  Flap  formed  after  Disarticulation. 


the  metatarsal  bone  of  the  little  toe,  carried  forwards  to  the  root  of  the 
toes  across  the  sole,  and  down  the  inner  side  to  behind  the  tubercle  of 

the  scaphoid  (Fig.  3t,  i).  This  flap  should  be 
made  broad,  especially  at  the  inner  side,  but  well 
rounded  at  the  angles,  and  should  consist  of  the 
whole  thickness  of  parts  in  the  sole  of  the  foot, 
which  must  be  well  dissected  out  from  the  con¬ 
cavity  under  the  metatarsal  bones.  A  convex 
incision  is  tlien  made  along  the  dorsum  from  one 
horn  to  the  other  of  the  plantar  flap ;  the  parts 
are  well  retracted,  and  the  articulations  opened 
by  the  Surgeon  bearing  firmly  upon  the  anterior 
part  of  the  foot,  and  lightly  touching  the  liga¬ 
mentous  structures  with  the  point  of  his  bistoury. 
In  this  stage  of  the  operation,  care  must  be 
taken  that  the  edge  of  the  bistoury  be  not  inclined 
too  much  backwards,  lest  it  slip  over  the  astra¬ 
galus  and  open  the  ankle-joint ;  or  too  far  for¬ 
wards,  lest  it  pass  anterior  to  the  scaphoid — 
between  it  and  the  cuneiform  bones.  After  dis¬ 
articulation  has  been  produced,  the  projecting 
head  of  the  astragalus  and  the  articular  surface 
of  the  os  calcis  should  be  sawn  off.  In  more 
1.  Line  of  amputation  of  instance,  I  liave  found  firm  osseous 

Operation ;  3.  Line  of  Eitdsioa  aiikylosis  existing  111  the  line  of  articulations,  so 
of  Os  Calcis  as  to  require  the  use  of  the  saw  for  the  separation 

of  the  anterior  part  of  the  foot.  The  result  of 
this  operation  is  extremely  favorable,  the  patient,  b}?"  the  aid  of  a  pro¬ 
perly  constructed  boot,  being  able  to  walk,  and  even  dance,  with  very 
little  appearance  of  lameness.  In  some  cases,  where  the  muscles  of  the 
calf  are  very  strong,  and  the  calcaneum  projects,  the  heel  becomes  drawn 
up,  and  the  centre  edge  of  the  stump  made  to  point  down  in  such  a  way 


Fig.  37. 


DISAETICULATION  AT  THE  AXKLE-JOIXT. 


75 


that  the  patient  is  rendered  lame  by  walking  on  the  anterior  sharp  edge 
of  the  calcaneiim,  which  irritates  the  flap.  This  condition  is  best 
removed  by  division  of  the  tendo  Achillis. 

Disarticulation  of  the  Foot  at  the  Ankle-joint  was  flrst  reduced  b}^ 
S3’me  to  a  regular  operation.  By  its  performance  amputation  of  the 
leg  ma}^  often  be  avoided,  the  patient  being  left  with  an  exceedingly 
useful  stump,  which,  as  its  covering  is  ingeniousl}"  taken  from  the  heel, 
constitutes  an  excellent  basis  of  support.  Sjune’s  words  as  to  the  direc¬ 
tion  of  the  incision  are:  “The  foot  being  held  at  a  right  angle  to  the 
leg,  the  point  of  the  knife  is  introduced  immediately'  below  the  malleolar 
projection  of  the  fibula,  rather  nearer  its  posterior  than  anterior  edge, 
and  then  carried  across  the  bone,  slightly'  inclining  backwards,  to  the 
inner  side  of  the  ankle,  where  it  terminates  at  the  point  exactly  opposite 
its  commencement”  (that  is,  a  little  below  and  behind  the  internal  mal¬ 
leolus).  “  The  extremities  of  this  incision  thus  formed  are  then  joined 
by'  another  passing  in  front  of  the  joint.  The  operator  next  proceeds  to 
detach  the  flap  from  the  bone”  (Fig.  38).  The  object  of  canying  the 
incision  so  far  back  is,  that  the  dissection  of  the  flap  may^  commence 
from  the  most  prominent  point  of  the  plantar  surface  of  the  os  calcis, 
that  is  to  say^,  from  the  anterior  part  of  the  two  tuberosities  of  that 
bone.  Every  eighth  of  an  inch  in  front  of  this  point  increases  the  diffl- 

Fig.  38.  Fig.  39. 


Syme’s  Amputation  of  the  Foot.  Clearing  Syme’s  Amputation  of  the  Foot.  Anterior  In- 

the  Os  Calcis.  cision  and  Disarticulation. 

culty'  of  raising  the  flap.  The  lateral  ligaments  should  now  be  touched 
with  the  point  of  the  bistoury,  and  the  tendo  Achillis  divided  by^  pressing 
the  foot  forcibly'  downwards  and  cutting  from  before  backwards  by  some 
twisting  and  dissection,  at  the  same  time  the  os  calcis  is  completely' 
separated  from  its  soft  attachments,  and  the  foot  removed  (Fig.  39)  ;  the 


76 


SPECIAL  AMPUTATIONS. 


two  malleoli  must  then  be  sawn  off  (Fig.  41),  the  plantar  arteries  tied, 
and  the  flap  brought  up.  A  well-formed  rounded  stump  will  thus  be 


left. 


Fig.  40. 


In  performing  this  operation,  care  must  be  taken  that  no  button-hole 
apertures  be  made  through  the  posterior  part  of  the  heel  flap.  This 
may  commonly  be  avoided  readily  enough  when  the  soft  structures  in 
this  situation  are  greatly  thickened  and  infiltrated  by  plastic  matter,  as 
the  result  of  chronic  disease  ;  but,  if  the  operation  be  required  for  injury 
of  the  foot,  great  care  is  required  in  digging  out  the  heel,  the  integu¬ 
ments  at  the  posterior  part  of  the  os  calcis  being  veiy  thin  and  adherent 

to  the  bone.  It  is  also  of  importance 
that  the  incision  across  the  heel  should 
be  carried  well  back  over  its  point 
(Fig.  40).  Unless  this  be  done,  a  large 
cup-shaped  flap  will  be  left,  in  which 
blood  and  pus  will  accumulate,  and  the 
cicatrization  of  the  stump  will  be  much 
retarded.  As  union  takes  place  by 
granulation,  there  will  be  a  tendency  to 
bagging  in  the  stump  ;  but  this  may  be 
prevented  by  proper  bandaging.  The 
tendency  to  sloughing  and  to  undue  suppuration  chief!}'  occurs  in  those 
cases  in  which  the  amputation  has  been  performed  as  a  primary  opera- 


Syrae’s  Disarticulation  at  Ankle-joint. 


Fig.  41. 


Syme’s  Amputation  of  the  Foot.  Sawing  off  the  Malleoli. 


tion  for  a  crush  of  the  foot.  In  one  case  in  which  I  had  occasion  to 
perform  it  for  an  injury  of  this  kind,  a  good  deal  of  trouble  resulted 
from  this  cause,  though  eventually  the  case  did  perfectly  well,  and  the 
patient  now  walks  with  scarcely  any  difficulty.  It  has  been  frequently 


pieogoff’s  amputation. 


77 


stated  that  it  is  necessary,  in  order  to  ensure  the  vitality  of  the  flap,  to 
cut  the  posterior  tibial  artery  “  as  long  as  possible,”  and  it  is  this  as 
much  as  anything  that  has  led  to  the  production  of  the  huge  cup-shaped 
flaps  which  are  so  difficult  to  dissect  off  the  os  calcis,  and  which  so  often 
slough.  A  careful  examination  of  the  vascular  suppl}^  of  the  flap  will 
show  at  once  that  the  posterior  tibial  artery  may  be  cut  close  to  the  base 
of  the  flap,  without  in  the  least  interfering  with  the  chief  vessels  sup¬ 
plying  it.  The  distribution  of  vessels  to  the  part  is  as  follows :  On  the 
outer  side,  the  peroneal  artery,  after  giving  off  the  anterior  peroneal, 
is  continued  down  along  the  posterior  aspect  of  the  fibula  to  the  outer 
side  of  the  os  calcis.  On  the  inner  side  a  branch  of  considerable  size 
arises  from  the  posterior  tibial  arteiy,  about  one  and  a  half  to  two 
inches  above  the  ankle-joint,  and  passes  down  to  the  inner  side  of  the  os 
calcis,  running  behind  the  inner  malleolus  and  accompanying  the  small 
cutaneous  nerve  from  the  posterior  tibial  to  the  skin  of  the  heel.  There 
is  thus  a  main  trunk  on  each  side  running  down  to  the  heel  behind  the 
malleolus,  and  these  two  communicate  freely  with  each  other  both  super¬ 
ficially  over  the  cutaneous  surface  of  the  tendo  Achillis,  and  deeply 
between  the  tendon  and  the  back  of  the  ankle-joint ;  and  the}^  terminate 
by  anastomosing  again  by  long  vascular  loops  on  the  under  surface  of 
the  posterior  part  of  the  os  calcis.  It  is  upon  these  anastomosing  loops 
that  the  vitality  of  the  flap  depends  more  than  upon  anything  else ;  and 
as  they  lie  much  nearer  the  bone  than  the  skin  it  is  evident  that,  unless 
the  knife  be  kept  hard  upon  the  bone  during  the  whole  dissection  of  the 
flap,  they  will  be  divided  in  large  numbers,  greatly  endangering  its 
vitality.  In  the  operation  as  performed  by  Syme,  the  dissection  of  the 
flap  is  commenced  from  the  most  prominent  part  of  the  tuberosities  of 
the  os  calcis,  and  the  knife  can  be  kept  in  constant  contact  with  the 
bone  with  the  greatest  ease.  If,  on  the  contraiy,  the  flap  extend  far  into 
the  sole  of  the  foot  in  front  of  the  tuberosities  of  the  os  calcis,  it  is 
almost  impossible  to  dissect  it  back  without  the  point  of  the  knife  being 
directed  into  the  under  surface  of  the  flap,  and  the  vascular  loops  being 
divided.  All  the  above-mentioned  vessels  can  be  readily  dissected  out 
in  any  well-injected  foot  in  the  dissecting-room.  I  look  upon  this  ope¬ 
ration  as  a  most  useful  one  in  all  cases  requiring  removal  of  the  whole 
foot.  The  mortality  attending  it  is,  I  believe,  but  small.  I  have  per¬ 
formed  it  nine  times  without  a  fatal  r’esult  or  disagreeable  consequence ; 
and  the  stump  that  is  left  admits  of  good  pressure  being  exercised 
directly  upon  it,  without  tenderness  or  fear  of  ulceration. 

Various  modifications  of  Syme’s  amputation  may  at  times  be  practised 
with  advantage,  in  consequence  of  the  soft  parts  covering  the  heel  being- 
more  or  less  ulcerated  or  disorganized,  so  as  not  to  admit  of  forming  a 
•good  basis  of  support.  In  these  circumstances,  the  flaps  may  be  fash¬ 
ioned  from  the  sides  instead  of  from  behind  ;  and  in  this  way  I  have 
more  than  once  formed  an  excellent  covering  to  the  end  of  the  stump. 
These  lateral  flaps  should  not,  however,  be  made  in  any  case  that  admits 
disarticulation  at  the  ankle  in  the  ordinary  way.  They  never  afford  so 
good  a  basis  of  support  as  the  integuments  of  the  heel,  which  are  far 
more  dense  and  elastic. 

Pirogoffh  Amputation  is  characterized  by  the  preservation  of  the  pos¬ 
terior  portion  of  the  os  calcis,  which  is  left  in  the  heel-flap.  The  operation 
is  performed  in  the  following  way.  An  incision  is  carried  across  the  sole 
of  the  foot  from  one  malleolus  to  the  other.  This  incision  must  not  be 
made  directly  transverse  to  the  foot,  but  should  incline  forwards  obliquely, 
so  that  the  centre  of  the  incision  in  the  sole  may  be  at  least  an  inch  in 


78 


SPECIAL  a:mputatioxs. 


front  of  a  line  drawn  across  from  the  tip  of  one  malleolus  to  the  other. 
The  flap  thus  traced  is  dissected  back  for  about  two  lines.  Disarticula¬ 
tion  of  the  astragalus  is  then  affected  in  the  usual  wa}",  b}"  an  incision 
across  the  front  of  the  foot.  A  narrow  amputating  or  a  Butcher’s  saw 
is  now  applied  to  the  upper  and  back  part  of  the  os  calcis  behind  the 
astragalus  (Fig.  42),  and  the  bone  cut  obliquel}'  downwards  and  well 
forwards ;  the  malleoli  are  then  removed,  and  a  thin  slice  of  the  tibia 
with  the  articular  cartilage  taken  off  (Fig.  43).  The  opposed  osseous 


PirogofiF’s  Amputation:  Ap¬ 
pearance  of  parts  after  Ke- 
moval  of  Malleoli. 


PirogofiF’s  Amputation:  Application  of  Saw  to  Os  Calcis, 


Fig.  44. 


surfaces  must  then  be  accurately  adjusted,  the  movable  flap  well  sup¬ 
ported  b}'  a  broad  strip  of  plaster,  and  the  limb  laid  on  the  outer  side, 
with  the  knee  placed  so  as  to  take  off  the  tension  of  the  tendo  Achillis. 
The  advantages  of  this  operation  over  the  ordinary  modes  of  disarticula¬ 
tion  consist  in  the  stump  being  longer,  to  the  extent  of  the  thickness  of 
tlie  portion  of  the  os  calcis  left  in  it,  and  being  better  adapted  for  pres¬ 
sure  (Fig.  44)  ;  in  the  readiness  of  the  union  of  the  two  applied  osseous 
surfaces;  and  in  the  less  likelihood  of  the  suppl}’  of  blood  to  the  poste¬ 
rior  flap  being  interrupted,  as  its  vascular  communi¬ 
cations  are  not  much  disturbed,  and  the  plantar  arte¬ 
ries  can  alwa3’S  be  cut  long.  These  advantages  are  not, 
however,  alwa3’s  real,  and  are  in  some  degree  counter¬ 
balanced  b3’  the  liability  to  recurrence  of  disease  in  the 
portion  of  the  os  calcis  left  in  those  cases  in  which  the 
amputation  is  done  for  disease.  When  it  is  practised 
for  injuiy,  however,  this  objection  does  not  hold  good. 
Another  objection  "which  has  been  raised  against  this 
operation,  consists  in  the  supposition  that  the  section 
of  two  osseous  surfaces  exposes  the  patient  to  increased 
risk  of  osteophlebitis  and  p3’0emia.  In  the  first  case 
in  which  I  performed  this  amputation  the  patient,  a 
health3’  lad,  whose  foot  was  removed  for  injuiy,  died 
from  this  cause.  But  subsequent  and  extended  expe- 
stump  after  Piro<-ors  I’iciice  lias  coiiviiiced  me  that  there  is  no  special  liabilit3’ 
Amputationr  to  pyicmia  after  Pirogoff'’s  amputation  after  its  per- 


AMPUTATION  OF  THE  LEG.  79 

forraaiice,  patients  can  run;  which  they  cannot  do  after  amputation  of  the 
leg  ill  any  part. 

The  Subastragaloid  Amputation  is  another  mode  of  disarticulating  the 
foot.  In  it  the  heel-flap  is  made  as  in  S3’me’s  operation,  and,  the  articu¬ 
lation  between  the  astragalus  and  scaphoid  being  opened  (the  ankle-joint 
left  intact),  the  bistouiy  is  passed  under  the  astragalus,  between  it  and 
the  calcaneiim,  whicli  together  with  the  rest  of  the  foot  is  removed. 
In  this  amputation  a  good,  long,  useful  stump  results;  but  the  cases 
requiring  it  must  be  few,  as  it  does  not  often  happen  that  there  is  disease 
of  the  calcaneum  together  with  the  anterior  range  of  tarsal  bones,  with¬ 
out  the  astragalus  also  being  involved. 

In  cases  of  caries  of  the  tarsus  requiring  amputation,  it  occasionally 
happens  that  the  Surgeon  cannot  determine  with  certain!}"  whether  the 
morbid  action  is  limited  to  the  anterior  range  of  tarsal  bones,  or  extends 
so  far  backwards  as  seriousl3’to  implicate  the  astragalus  and  calcaneum; 
and  he  is  consequent!}'  unable  to  decide  whether  the  condition  of  the  foot 
admits  removal  b3'Chopart’s  operation,  or  requires  disarticulation  at  the 
ankle-joint.  In  these  circumstances  all  doubt  will  be  cleared,  and  the 
proper  operation  performed,  b}'  making  an  incision  across  the  dorsum  of 
the  foot  in  the  line  of  the  astragalo-scaphoid  and  calcaneo-cuboid  articu¬ 
lations  ;  these  are  then  opened,  and  the  state  of  the  bones  is  examined. 
If  the  astragalus  and  calcaneum  be  sound,  or  but  slightl}"  diseased  on 
their  anterior  aspect,  Chopart’s  operation  ma}'  be  done,  and  an}'  carious 
bone  left  behind  gouged  away.  If,  on  the  contrary,  these  bones  be  found 
to  be  deeply  implicated,  the  flap  maybe  dissected  back  for  about  an  inch, 
and  disarticulation  at  the  ankle-joint  proceeded  with.  It  may  also  be 
well  to  bear  in  mind  that  the  tarsal  articulations  may  have  become  so 
anchylosed,  as  the  result  of  old  disease,  as  to  require  the  application  of 
the  saw. 

JResiilts. — The  amputation  of  a  toe,  of  a  metatarsal  bone,  or  even  of  a 
portion  of  the  metatarsus,  is  but  very  seldom  attended  by  fatal  conse¬ 
quences.  Should  death  occur,  it  is  usually  the  result  of  an  accidental 
attack  of  erysipelas,  followed  by  pyaemia,  to  which  any  operation  is 
liable.  Disarticulation  at  the  ankle-joint,  though  necessarily  somewhat 
more  dangerous,  is  yet  one  of  the  most  successful  operations  in  Surgery, 
the  mortality  attending  it  being  but  very  small.  Of  nine  cases  in  which 
I  have  done  it,  not  one  has  proved  fatal. 

Amputation  of  the  Leg  may  be  performed  in  three  situations : 
either  just  below  the  knee,  in  the  middle  or  in  the  lower  third  of  the 
limb.  The  selection  of  the  line  of  amputation  must  depend  in  a  great 
degree  upon  the  extent  of  the  disease  or  injury,  but,  whenever  practi¬ 
cable,  the  operation  should  be  performed  low  down;  the  mortality  dimin¬ 
ishing  in  proportion  as  the  limb  is  removed  near  to  the  ankle.  Of  106 
amputations  in  this  situation  done  in  Paris,  there  were  only  13  deaths. 
Surgeons  used  formerly,  even  when  the  disease  or  injury  was  limited  to 
the  foot,  to  amputate  immediately  below  the  knee,  in  all  those  cases  in 
which  the  patient  would  be  obliged  to  wear  a  common  wooden  pin,  the 
long-leg  stump  being  highly  inconvenient  when  the  patient  rested 
on  his  bent  knee ;  whereas,  in  those  individuals  who  could  afford 
the  expense  of  a  well-constructed  artiflcial  limb,  the  amputation,  when 
practicable,  was  done  in  the  lower  part  of  the  leg.  But  this  difficulty 
has  of  late  years  been  removed  by  the  introduction  of  a  short  wooden 
pin,  in  the  socket  of  which  the  stump  may  be  fixed  in  the  extended 
position  ;  and  amputation  in  all  admissible  cases  should  consequently, 
even  amongst  the  poorer  classes,  be  done  just  below  the  calf,  at  the  junc- 


80 


SPECIAL  AMPUTATIONS. 


tion  of  the  lower  and  middle  thirds  of  the  limb ;  nearer  the  ankle  than 
this,  it  is  not  easj"  to  get  a  good  covering  for  the  ijones. 

Flap  Amputation  of  the  Leg  may  be  perform.ed  in  the  following  way. 
The  tourniquet  having  been  applied  to  the  artery  in  the  popliteal  space, 
the  assistant,  whose  duty  it  is  to  retract  the  flap,  takes  his  stand  in  this, 
as  in  all  amputations  of  the  lower  extremities,  opposite  to  the  Surgeon. 
In  the  left  limb,  the  point  of  the  knife  is  entered  at  the  posterior  edge  of 
the  tibia,  carried  forwards  for  a  distance  of  one  inch  and  a  half  to  two 
inches,  then  across  the  anterior  part  of  the  leg  to  the  posterior  border 
of  the  fibula,  up  which  the  incision  is  made  to  extend  to  a  corresponding 
distance.  In  the  right  leg  the  same  incision  commences  on  the  fibular 
side  of  the  limb,  and  terminates  on  the  tibial.  The  flap  thus  formed, 
which  should  be  broad  and  well  rounded,  is  next  dissected  up  b}'  a  few 
touches  of  the  point  of  the  knife,  and  transfixion  of  the  limb  is  made  by 
passing  the  blade  across  behind  the  bones,  from  one  angle  of  the  incision 
to  the  other  (Fig.  45).  The  posterior  flap  is  then  formed  b}’  cutting 


Fig.  45. 


obliquely  downwards  and  backwards,  and  should  be  about  three  inches 
long.  The  bones  are  next  cleared  b}'^  a  double  sweep  of  the  knife,  and 
the  interosseous  soft  parts  divided  b^^  canning  the  instrument  in  a  figure- 
of-8  way  between  the  bones.  In  doing  this,  especial  care  must  be  taken 
not  to  direct  the  edge  upwards,  so  as  to  split  either  of  the  tibia  arteries, 
more  particularly  the  anterior ;  for,  as  this  vessel  retracts  above  the 
membrane,  its  ligature,  when  divided  too  high,  is  no  eas}"  matter.  If  the 
amputation  be  performed  just  below  the  knee,  it  is  possible  that  the 
popliteal  trunk  may  be  divided  before  its  bifurcation,  and  thus  one 
artei’}^  onl}'  require  the  ligature.  In  sawing  the  bones,  the  fibula  should 
always  be  cut  first,  as  otherwise  it  will  be  nearly  sure  to  be  splintered. 


AMPUTATION  OF  THE  LEG. 


81 


This  bone  may  be  best  divided  on  the  left  side,  by  sinking  the  hand 
below  the  level  of  the  limb,  and  using  the  heel  of  the  saw  ;  and  on  the 
right,  by  holding  the  hand  above  the  limb,  and  cutting  with  the  end  of  the 
instrument  (Fig.  46).  After  the  removal  of  the  limb,  the  sharp  anterior 


Amputation  of  the  Leg.  Sawing  the  Bones. 


edge  of  the  tibia  may  advantageously  be  sliced  off  obliquely,  so  as  to 
lessen  the  risk  of  sloughing  of  the  corresponding  flap  from  pressure 
upon  a  sharp  ridge  of  bone. 

If  the  limb  be  very  muscular,  a  large  pad  of  the  muscles  of  the  calf 
will  be  left  in  the  posterior  flap ;  this  will  usually  be  a  good  deal  in  the 
way  during  treatment ;  it  may  slough,  and  thus  interfere  with  proper 
union.  In  some  cases,  I  have  advantageously  removed  at  one  sweep  of 
the  knife  the  greater  part  of  the  muscular  mass  thus  left,  thus  leaving 
little  more  than  a  skin-flap  ;  but,  in  order  to  avoid  this,  the  best  operation 
consists,  in  such  cases  as  these,  in  forming  skin-flaps  on  the  anterior  and 
posterior  aspects  of  the  limb,  and  then  making  a  circular  cut  through 
the  muscles.  In  this  way  the  ends  of  the  bones  receive  but  a  thin 
covering;  but  this  matters  little  if  the  operation  be  performed  just 
below  the  knee,  for  the  patient,  bearing  upon  the  anterior  face  of  the 
stump,  exercises  no  pressure  upon  its  cicatrix  when  an  artificial  limb  is 
adapted  to  it. 

Results. — Amputation  of  the  leg  may,  upon  the  whole,  be  looked  upon 
as  a  successful  operation.  The  mortalit}",  however,  varies  not  only 
according  to  the  situation  at  which  the  limb  is  removed,  but  also  accord¬ 
ing  as  it  is  done  for  injury  or  disease,  and  the  nature  of  that  disease. 
So  far  as  situation  is  concerned,  it  may  be  stated,  as  a  general  rule,  that 
the  nearer  the  knee  the  greater  is  the  danger. 

In  amputation  of  the  leg  for  injury,  the  rate  of  mortality  is,  upon  the 
whole,  rather  high.  In  the  Crimea,  3t  per  cent,  of  the  cases  were  lost. 
The  table  at  page  55  shows  an  average  mortality  in  civil  practice  of  46T 
per  cent. ;  the  death  rate,  however,  varies  greatly  in  the  records  of  dif- 
VOL.  I. — 6 


82 


SPECIAL  AMPUTATIONS. 


ferent  hospitals.  Thus,  at  the  Edinburgh  and  Glasgow  Infirmaries,  and 
Gi\y’s  Hospital,  in  an  aggregate  of  224  cases,  there  were  116  deaths; 
while  in  353  cases  in  country  hospitals,  the  number  of  deaths  was  99, 
and  in  66  cases  at  St.  Bartholomew’s  Hospital,  there  were  20  deaths. 
At  University  College  Hospital,  the  mortality  has  been  3U8  per  cent. 
Secondary  amputation  is  more  fatal  than  primary ;  the  deaths  from  the 
former,  according  to  the  table  at  page  51,  being  48,  and  from  the  latter, 
43-9  per  cent.  After  amputation  of  the  leg  for  disease,  the  mortalit}'  is 


much  smaller 


amounting  on  a 


calculation  based  on  1281  cases,  to  23*5 


Fis;. 


47. 


per  cent.  The  chief  causes  of  death  are  j^A’semia,  gangrene  of  .the  stump, 
and  exhaustion. 

Amputation  through  the  Knee-joint,  originall}^  recommended 
in  the  last  centuiy  by  Hoin,  and  reintroduced  by  Yelpeau,  Markoe,  and 
Brinton,  has  for  some  3'ears  found  favor  in  this  country  and  in  America. 

Amputation  through  the  knee-joint  maybe  performed  in  three  different 
waj’S ;  1,  with  a  long  posterior  and  a  short  anterior  flap  ;  2,  with  a  long 
anterior  and  a  short  posterior  flap  ;  3,  b}^  lateral  flaps. 

1.  The  operation  with  the  Long  Losterior  and  Short  Anterior  Flap 
ina}’  be  readilj^  performed  in  the  following  wa3^  An  incision  is  made 
directly  across  the  knee-joint,  just  below  the  patella.  The  skin-flap  thus 
formed  is  dissected  back ;  and,  the  joint  being  opened  above  the  patella, 
and  the  ligaments  divided  b}"  a  few  touches  of  the  knife,  a  long  posterior 
flap  is  cut  from  the  upper  part  of  the  calf  of  the  leg,  b}"  passing  the 
knife  behind  the  tibia,  and  cariying  it  downwards  for  a  suitable  distance. 

2.  The  operation  by  means  of  a  Long  Anterior  and  a  Short  Posterior 
Flag),  is  thus  performed.  A  long  square  flap,  rounded  at  the  corners,  is 

made  by  entering  the  point  of  a  short  broad- 
bladed  amputating-knife  towards  the  posterior 
part  of  one  cond3de,  canying  the  incision  down¬ 
wards  in  a  straight  line  for  four  or  five  inches, 
then  across  the  limb,  and  cutting  upwards  to  a 
point  on  the  opposite  side  corresponding  to  that 
of  entiy.  The  integuments  and  the  patella  are 
then  dissected  from  the  front  of  the  joint  (Fig. 
41).  The  articulation  is  thus  opened;  the  liga¬ 
ments  are  then  successivel3"  divided,  the  limb 
being  forcibl3^  bent ;  and  a  short  posterior  flap 
formed  b3’  cutting  with  a  determined  sweep  from 
behind  forwards.  The  popliteal  arteiy  is  divided 
in  all  these  cases,  and  with  the  exception  of  the 
other  articular  vessels  is  the  only  one  requiring 
ligature. 

The  management  of  the  patella  is  an  important 
question;  some  Surgeens  advocating  its  removal, 
and  others  its  preservation.  I  think  that  it  is 
decidedly  better  to  leave  than  to  remove  this 
bone.  If  left,  it  forms  an  important  addition  and 
protection  to  the  end  of  the  stump.  If  it  be  re¬ 
moved,  not  only  are  these  advantages  lost,  but 
the  flap  becomes  so  thinned  and  weakened  as  to 
incur  danger  of  gangrene.  I  have  practised 
the  operation  both  wa3’S,  and  have  from  1113^  ex¬ 
perience  found  it  most  advantageous  to  leave  the 
patella.  There  is  onl3’  one  objection  to  this;  and  that  is  the  chance  of 
the  patella  being  drawn  up,  as  occasionall3’  happens,  upon  the  anterior 


Amputation  tlirougb  the  Knee 
by  Long  Anterior  Flap. 


AMPUTATION  AT  THE  KNEE. 


83 


part  of  tbe  thigh.  This  is  best  prevented  b}’  turning  up  the  flap,  and 
cutting  across  the  tendinous  insertion  of  the  quadriceps  extensor. 

Aljout  the  management  of  the  cartilaginous  surface  of  the  femur  in 
these  amputations,  there  is  a  diflerence  of  practice.  Some  Surgeons 
prefer  leaving  it ;  others,  again,  saw  it  off.  If  the  articular  surface  be 
sound,  the  cartilage  had  better  be  left,  as  thus  the  cancellous  structure 
is  not  opened,  and  one  source  of  pyrnmia  is  removed.  If  the  cartilages 
be  eroded  or  otherwise  diseased,  the^^  should  be  removed.  This  I  gene¬ 
rally  do,  after  the  disarticulation  has  been  completed,  by  means  of  a  fine- 
bladed  Butcher’s  saw,  cutting  around  and  not  across  the  end  of  the  bone; 
thus  not  shortening  the  stump,  but  simply  removing  the  cartilage,  which 
would  otherwise  necrose  or  disinteg-rate,  and  thus  interfere  with  readv 
union.  The  inner  surface  of  the  patella  should  be  removed  in  a  similar 
manner,  and  the  flap  then  laid  down. 

This  will  be  found  to  furnish  an  excel¬ 
lent  covering  to  the  bone  ;  the  patella, 
and  the  thick,  tough,  and  extensile 
integuments  of  the  knee,  forminof  a 

O  y  o 

good  basis  of  support  for  the  limb  to 
bear  upon,  and  one  well  adapted  for 
pressure. 

3.  S.  Smith,  of  Xew  York,  ampu¬ 
tates  at  the  knee  b}'  Lateral  Flaps 
in  the  following  wa}'.  The  incision 
is  commenced  about  an  inch  below 
the  tubercle  of  the  tibia,  and  is  car¬ 
ried  downwards  and  forwards  over 
the  most  prominent  part  of  the  side 
of  the  leg,  until  it  readies  the  under 
surface,  where  it  is  carried  towards 
the  median  line.  When  this  point  is 
reached,  it  is  carried  directl}’  upwards 
to  the  centre  of  the  articulation,  A 
second  incision  begins  at  the  same  point  as  the  first,  and  pursues  a 
similar  direction  on  the  opposite  side  of  the  limb ;  the  two  incisions 
meeting  in  the  median  line  behind.  The  inner  flap  should  be  rather  the 
larger;  and  the  patella  is  left.  After  this  amputation,  the  stump  pre¬ 
sents  the  appearance  represented  in  Fig.  49. 

The  amputation  may  sometimes  be  conveniently  varied  by  being  done 
through  the  condyles  without  previously  opening  the  knee-joint.  This 
operation  maj-  be  done  with  a  long  posterior  flap  (Fig.  48)  or  a  long 
anterior  one  containing  the  patella.  Of  the  two  methods,  I  prefer  the 
latter,  as  giving  the  best  subsequent  result  with  least  cicatrix.  The 
advantages  of  this  operation  over  amputation  of  the  thigh  higher  up  are 
undoubtedl}"  great.  The  limb  being  removed  at  a  greater  distance  from 
the  trunk,  the  shock  to  the  sj’stem  will  be  less,  and  the  rate  of  mortality 
diminished  ;  the  medullaiy  canal  of  the  femur  not  being  opened,  there 
will  be  less  likelihood  of  osteom3’elitis ;  fewer  ligatures  will  be  required, 
and,  if  a  long  posterior  flap  have  been  made,  these  ma}'  be  brought  out 
through  an  opening  made  in  the  centre  of  it,  as  Blandin  recommends ; 
and  lasth’,  a  longer  stump  will  be  left,  the  movements  of  which  will  be 
more  under  the  control  of  the  patient  than  those  of  a  shorter  one,  owing 
to  the  proper  muscles  of  the  femur  not  being  divided,  and  all  the  move¬ 
ments  of  that  bone  being  thus  preserved  in  their  integrit}'.  There  is  a 
little  point  of  practice  that  I  have  found  useful  in  this  amputation ;  viz.,. 


Fig.  48, 


Amputation  through  the  Condvles  b7  Long 
Posterior  Flap. 


SPECIAL  AMPUTATIONS. 


yj- 

to  round  off  with  the  saw  the  sharp  edge  left  on  the  condyle  after  the 
removal  of  its  cartilaginous  surface,  as  this  otherwise  ma}"  press  injiiri- 
ousl}"  upon  the  flap.  In  the  after-treatment,  the  patella  should  be  kept 

Fig.  49. 


Amputation  at  Knee  by  Lateral  Flaps. 


in  its  place  by  a  strip  of  plaster  well  brought  down  above  it ;  and  care 
must  be  taken  that  a  collection  of  pus  do  not  form  between  it  and  the  flat 
intercondjdoid  surface  of  the  femur.  This  may  be  avoided  by  syringing 
and  carefull}’’  dressing  up  the  stump. 

Results  of  Amputation  through  the  Knee-joint  or  Condyles  of  the 
Femur. — So  far  as  life  is  concerned,  these  operations  have  been  suc¬ 
cessful.  In  the  war  of  the  American  rebellion,  of  132  cases,  64  died, 
giving  a  mortality  of  48.4  per*cent.  Of  these,  49  were  primary  ampu¬ 
tations  ;  the  deaths  among  which  were  16,  or  22.6  per  cent.  Brinton 
gives  62  cases  of  amputation  through  the  knee  for  disease,  with  14 
deaths,  or  32.6  per  cent.  The  statistics  of  amputation  through  the  con- 
d^des  of  the  femur  immediatel}"  above  the  joint  have  not  been  made  out. 

These  amputations  present  three  great  advantages  over  those  higher 
up.  1.  As  the  medullary  canal  of  the  femur  is  not  opened,  the  patient 
is  saved  all  that  risk  which  results  from  suppuration  within  that  canal, 
the  infiltration  of  pus  into  it,  and  the  consequent  liability  to  suppurative 
phlebitis  of  the  veins  of  the  bone,  and  consecutive  pyaemia.  2.  He  is 
provided  with  a  long  thigh-stump,  which  gives  increased  leverage  in 
using  an  artificial  limb.  3.  When  the  amputation  is  practised  with  the 
long  anterior  flap  containing  the  patella,  the  end  of  the  stump  will  be 
protected  by  the  dense  and  tough  integumental  and  aponeurotic  struc¬ 
tures  naturall}'  situated  in  front  of  the  knee-joint,  which  admit  of 
pressure  being  made  upon  them  without  fear  of  excoriation:  the  cicatrix 
being  drawn  up  behind  the  end  of  the  stump,  and  altogether  away  from 
its  surface. 


AMPUTATION  OF  THE  THIGH. 


85 


Amputations  of  the  thigh  are  commonly  required  both  for  acci¬ 
dent  and  for  disease.  They  ma}'  be  performed  in  three  situations: 
immediate!}^  above  the  knee,  in  the  middle  of  the  limb,  or  in  its  upper 
third.  Amputation  just  above  the  knee  is  best  done  by  lateral  flaps  ; 
for  this  reason,  that  the  mass  of  muscle  in  this  part  of  the  thigh  lies  on 
each  side  of  the  limb,  the  central  portion  being  occupied  in  front  hy  the 
tendinous  and  aponeurotic  structures  connected  with  the  patella,  and 
behind  b\^  the  upper  triangle  of  the  popliteal  space :  hence,  if  antero¬ 
posterior  flaps  be  made  here,  the}^  will  be  thin  and  tendinous  in  the 
middle  ;  whereas  the  lateral  flaps  are  uniformly  thick  and  flesh}^  In  the 
middle  and  upper  thirds  of  the  thigh,  the  antero-posterior  flaps  leave 
the  best  result,  and  give  the  best  covering  to  the  bone.  If  lateral  flaps 
be  made  in  these  situations,  the  end  of  the  bone  is  apt  to  be  drawn  up 
into  the  angle  of  the  wound  between  the  flaps,  which  fall  away  behind  it. 
In  amputation  in  the  lower  or  middle  third,  a  tourniquet  may  be  applied 
high  on  the  limb  ;  but  when  the  operation  is  done  in  the  upper  third, 
there  is  no  space  for  the  application  of  this  instrument,  and  the  Surgeon 
must  then  trust  to  an  assistant  compressing  the  artery  as  it  passes  over 
the  brim  of  the  pelvis.  Compression  is  best  made  by  grasping  the  great 
trochanter  with  the  fingers  of  the  right  hand,  and  then  applying  the 
thumb  firmly  over  the  arterj^ ;  upon  this  the  other  thumb  is  then 
pressed  as  firmly  as  possible,  and  thus  all  chance  of  letting  the  vessel 
slip  is  prevented. 

Amputation  above  the  Knee^  or  Vermale^s  Operation^  is  best  done  by 
lateral  flaps.  In  performing  this  operation,  the  outer  flap  should  always 
be  made  first.  The  point  of  the  knife,  being  entered  in  the  middle  of 
the  thigh,  about  three  inches  above  the  upper  border  of  the  patella,  is 
carried  close  round  the  bone  and  brouijht  out  throimh  the  centre  of  the 
ham  ;  the  flap  is  then  cut  downwards  and  outwards ;  the  knife,  being 
entered  again  in  the  upper  angle  of  the  incision,  is  carried  close  round 


Fig.  50. 


the  bone  to  its  inner  side,  and  the  inner  flap  made  by  a  sweeping  cut 
(Fig.  50).  Unless  the  blade  be  kept  in  contact  with  the  bone  in  this 
situation,  the  femoral  artery  is  veiy  apt  to  be  split.  The  flaps  being 
then  retracted,  the  bone  is  cleared  by  two  sweeps  of  the  knife,  and  sawn 
about  four  inches  above  its  articular  surface. 


86 


SPECIAL  AMPUTATIONS. 


Amputatiou  of  the  Thigh;  Antero-posterior  Flap 
Operation. 


Fig.  53. 


In  the  Middle  or  Upper  Third  of  the  Thigh  the  Antero-posterior  Flap 
Operation  is  to  be  preferred.  In  ordinary  cases,  the  anterior  flap  inaj^ 
first  be  made,  and  the  posterior  one  subsequently  fashioned  b}^  trans¬ 
fixion  (Fig.  51).  If,  however,  the 
Fig.  51.  patient  be  very  much  emaciated, 

it  is  difficult  to  get  a  good 
cushion  from  the  anterior  part 
of  the  thigh  in  this  way  ;  and  it 
is  cousequeutly  preferable  to  fol¬ 
low  the  plan  recommended  by 
Mr.  Luke,  of  making  the  poste¬ 
rior  flap  first  by  transfixion,  and 
the  anterior  one  afterwards  by 
cutting  from  without  inwards 
(Fig.  52).  In  some  instances  in 
which  the  tissues  at  the  posterior 
part  of  the  thigh  are  much  dis¬ 
eased  or  injured,  whilst  those  on 
the  anterior  aspect  of  the  limb 
are  sound,  a  very  good  stump 
may  be  fashioned  by  making  a 
long  square  anterior  flap  by 
transfixion,  and  then  cutting  at 
one  stroke  of  the  knife  through  the  soft  parts  at  the  posterior  aspect  of 
the  limb,  in  a  somewhat  oblique  direction  from  below  upwards.  The 

anterior  flap,  when  laid 
down,  will  form  the 
cushion  at  the  end  of 
the  stump.  If  the  pa¬ 
tient  be  excessively" 
muscular,  and  the  am¬ 
putation  be  a  primary 
one,  I  think  it  is  bet¬ 
ter  to  make  skin-flaps 
with  a  circular  incision 
through  the  subjacent 
soft  parts.  In  this 
way  the  large  gaping 
fleshy  stumps  are 
avoided,  which  com¬ 
monly  run  into  un¬ 
healthy  suppuration 
and  sloughini?,  leadinof 
to  the  death  of  the  pa¬ 
tient. 

Amputation  through  the  Trochanters  may  sometimes  be  advanta¬ 
geously  practised,  either  in  severe  compound  fractures  of  the  lower  part 
of  the  thigh,  or  in  cases  of  malignant  cartilaginous  or  osseous  tumor  of 
the  lower  and  middle  thirds  of  the  femur;  and  thus  the  more  severe 
and  dangerous  operation  of  disarticulation  at  the  hip  may  be  avoided. 
Indeed,  should  it  be  found,  after  section  of  the  bone,  that  it  is  so  much 
injured  or  diseased  as  to  require  removal  at  the  joint,  this  may  readily 
enough  be  done  by  dissecting  the  head  out  of  the  acetabulum  with  a 
strong  scalpel  or  bistouiy. 

Results. — The  mortality  after  amputation  of  the  thigh  is  very  con- 


Ampulation  of  Thigh  :  Formation  of  Posterior  Flap  by  Transfixion 
of  Anterior,  by  Cutting  from  without  inwards. 


AMPUTATION  AT  THE  HIP-JOINT. 


87 


sklerable  when  the  operation  is  done  for  injuiy,  more  particularly  for 
compound  fracture  of  the  femur  itself.  The  mortality  after  amputation 
for  injuiy  in  civil  hospitals  amounts,  according  to  the  table  at  page  55, 
to  59. T  per  cent.  In  the  French  Army,  in  the  Crimea,  and  in  Italy,  it 
was  veiy  fatal,  amounting  to  92  per  cent.  In  some  hospitals  primary 
amputation  of  the  thigh  seems  almost  invariabh’-  to  have  been  a  fatal 
procedure;  whilst  in  other  institutions  the  mortality  has  not  exceeded 
50  or  60  per  cent.  At  Guy’s  and  at  University  College,  secondary 
amputation  of  the  thigh  has  been  more  fatal  than  the  primary. 

The  result  of  amputation  of  the  thigh  for  disease  of  the  knee-joint 
depends  entirely  upon  whether  the  affection  is  acute  or  chronic.  In 
acute  suppurative  disorganization  of  tlie  knee,  amputation  of  the  thigh 
is  most  fatal ;  indeed,  so  high  is  the  rate  of  mortality,  that  it  is  doubtful 
whether  it  is  proper  to  perform  the  operation  in  that  stage  of  the  affec¬ 
tion.  In  chronic  knee-joint  disease,  on  the  other  hand,  the  operation  is 
most  satisfactory  and  successful ;  death  seldom  resulting  unless  it  has 
been  deferred  to  the  last  stage  of  exhaustion  The  general  percentage 
of  mortality  after  amputation  for  disease  is  about  32.5. 

The  causes  of  death  vary  according  to  the  condition  for  which  the  ope¬ 
ration  is  performed.  In  primary  traumatic  amputation,  the  fatal  event 
is  chiefly  brought  about  by  exhaustion,  traumatic  gangrene  of  the  stump, 
or  secondary  hemorrhage.  In  secondary  amputations,  and  in  those  for 
disease,  p3"8emia,  erysipelas,  and  exhaustion  are  the  usual  causes  of  death. 

Amputation  at  the  Hip-joint. — This  formidable  operation  is  of 
comparatively  recent  introduction  into  surgery.  During  the  early  part 
and  middle  of  the  past  centuiy,  its  practicability  was  warml}"  canv^assed 
in  France.  It  was  performed  on  animals  experimental^^  It  was  found 
that  patients  affected  with  ergotism,  whose  lower  extremities  had  become 
gangrenous,  and  had  separated  at  the  hip-joint,  survived  ;  and,  at  last, 
in  the  3^ear  1TT3,  the  first  successful  amputation  of  the  kind  was  performed 
by  Perrault,  of  St.  Maure.  In  the  next  year,  the  operation  was  done  in 
England  by  Kerr,  of  Northampton,  on  a  girl  aged  12,  affected  with  cox- 
algia  and  lumbar  abscess.  The  operation  was  unjustifiable  in  such  a 
case,  but  the  patient  lived  It  days  and  thus  its  practicabilit3^  was  demon¬ 
strated.  Larrey  performed  it  in  1793  for  the  first  time  for  gunshot 
injuiy  and  since  that  time  the  operation  has  become  an  established  one 
in  surgical  practice,  civil  as  well  as  military.  The  operation  was  first 
performed  successfully  in  England  in  1812,  by  Browning,  of  Plymouth, 
on  a  man  whose  thigh  had  been  broken  in  the  Peninsular  war  a  3’ear 
previously. 

Amputation  at  the  hip-joint  ma3"  be  and  has  been  performed  in  a 
variety  of  wa3'S,  which  it  is  not  necessary  to  detail.  The  most  conve¬ 
nient  methods  are  those  by  antero-posterior  and  by  lateral  flaps.  Of 
these,  that  by  antero-posterior  flap  is  the  simplest  and  speediest,  and 
leaves  the  best  stump.  It  consists  in  making  a  large  and  thick  anterior 
flap  by  transfixion,  and  a  short  posterior  one  from  the  gluteal  region  and 
back  part  of  the  thigh.  In  order  to  perform  this  operation  properly,  the 
patient’s  bod3^  must  be  brought  well  forward  upon  the  edge  of  the  table, 
so  that  the  nates  project  beyond  it,  and  be  steadied  by  strong  bandages. 
One  of  these  must  be  passed  between  the  sound  thigh  and  the  perinieum, 
and  attached  to  the  upper  end  of  the  table ;  anotlier  should  be  carried 
across  the  pelvis  to  the  lower  end ;  and  the  sound  limb  must  be  tied  to 
the  leg  of  the  table.  The  circulation  through  the  limb  should  then  be 
arrested  by"  the  application  of  Lister’s  compressor  to  the  abdominal 


88 


SPECIAL  AMPUTATIONS. 


aorta  (Fig.  53).  This  is  a  most  inYaliiable  instrument,  completely 
restraining  the  circulation  througli  the  lower  extremities,  depriving 

this  operation  of  its  great  danger — 
Fig.  53.  undue  loss  of  blood,  and  enabling 

the  Surgeon  to  complete  it  without 
huny  or  anxiety  on  this  account. 
It  should  be  applied  a  little  above 
and  to  the  left  of  the  umbilicus. 
The  Surgeon  must  have  three  assis¬ 
tants  on  whom  he  can  full}^  rely. 
Assistant  ^^o.  1  takes  charge  of  the 
flap,  compressing  the  femoral  ves¬ 
sels  ;  and,  in  the  absence  of  the 
abdominal  compressor,  on  his  trust¬ 
worthiness  the  patient’s  life  is 
mainly  dependent.  Assistant  Xo. 
2  takes  charge  of  the  limb;  flexing 
it  slightly  on  the  abdomen  in  the 
flrst  stage  of  the  operation,  whilst 
the  anterior  flap  is  being  made ; 
forcibly  abducting  and  bending  it  backwards  during  the  second  stage, 
when  the  Surgeon  is  opening  the  capsule  of  the  joint  and  making  the  pos¬ 
terior  flap.  On  the  way  in  which  he  performs  these  duties,  the  fadlitj’  with 
which  the  Surgeon  performs  the  operation  is  mainly  dependent.  To  assist¬ 
ant  Xo.  3  is  consigned  the  care  of  the  compressor  of  the  abdominal 
aorta.  After  the  removal  of  the  limb,  assistant  Xo.  2  aids  the  Surgeon 
in  ligaturing  the  arteries.  These  preliminaries  having  been  arranged 
and  the  duty  of  each  assistant  assigned  to,  and  distinctlj^  understood 
by  him,  the  operation  is  to  be  performed  in  the  following  way. 


Lister’s  Aorta-Compressor  applied. 


Fig.  54. 


Amputation  at  the  Hip-joint :  Formation  of  Anterior  Flap  in  Left  Limb. 


The  Surgeon,  standing  on  the  left  side  of  the  limb  to  be  removed,  feels 
for  the  bony  points  which  guide  his  knife,  viz.,  the  tuber  ischii  and  the 


AMPUTATION  AT  THE  HIP-JOINT. 


89 


anterior  superior  spine  of  the  ilium.  The  knife,  which  must  have  a  blade 
twelve  inches  long,  requires  to  be  entered,  and  the  flap  to  be  made,  in 
different  wa3'S,  according  to  the  side  of  the  bod}^  on  which  the  opera¬ 
tion  is  performed.  If  it  be  on  the  left  side,  the  knife  should  be  entered 
about  two  fingers’  breadth  below  the  anterior  superior  spine  of  the  ilium, 
or  midway  between  it  and  the  trochanter  major,  and  carried  deepl}’  in 
the  limb  behind  the  vessels,  directlj^  across  the  joint;  its  point  being 
made  to  issue  just  in  front  of  the  tuberosity  of  the  ischium  or  immedi¬ 
ately  behind  the  prominent  ridge  formed  by  the  tendon  of  the  abductor 
longus  (Fig.  54).  In  transfixing  on  this  side,  care  must  be  taken  not  to 
wound  the  scrotum  or  the  opposite  thigh  ;  the  back  of  the  knife  must 
run  parallel  to,  but  not  against  the  pelvis,  and  the  point  must  not  be 
held  too  high,  lest  it  enter  the  obturator  foramen.  The  anterior  flap 
must  then  be  rapidl^^  cut  downwards  and  forwards,  about  five  inches  iu 
length.  The  limb,  which  has,  during  tliis  stage  of  the  operation,  been 
raised  and  slightly"  flexed  upon  the  abdomen,  must  now  be  forcibly" 
abducted  and  everted  ;  the  capsule  of  the  joint  is  then  to  be  opened  b^' 
a  firm  cut  with  the  point  of  the  knife.  So  soon  as  this  is  done,  the  liead 
of  the  femur  must  be  pushed  up  bj^  forcibly'  depressing  and  abducting 
the  limb,  so  that  it  ma^"  start  out  of  the  ascetabulum  (Fig.  56);  the  heel 


Fig.  55. 


of  the  knife  is  then  passed  behind  it,  the  remainder  of  the  capsule  cut 
across,  and  the  posterior  flap  rapidl}^  fashioned  by  cariying  the  knife 
downwards  and  backwards  through  the  thick  muscles  in  this  situation. 
In  doing  this,  the  thigh  should  be  extended  and  rotated  inwards,  so  as 
to  clear  the  trochanter.  The  posterior  flap  maj^  be  about  four  inches  in 
length;  but  this  must  of  course  vary  according  to  the  length  of  the 


90 


SPECIAL  AMPUTATIONS. 


anterior  flap.  When  the  amputation  is  performed  on  tlie  right  side,  the 
anterior  flap  is  made  by  entering  the  knife  just  above  the  tuberosit}^  of 
the  ischium,  and  bringing  it  out  two  fingers’  breadth  below  the  anterior 
superior  spine  of  the  ilium  (Fig.  55) ;  the  remaining  steps  of  the  ope¬ 
ration  being  performed  as  in  the  last  case. 

In  consequence  of  the  extent  to  which  the  limb  that  is  about  to  be 
removed  may  have  been  injured,  or  to  wliich  it  is  encroached  upon  by 
disease,  it  is  not  always  eas}^  to  make  the  anterior  flap  of  the  size  or 
shape  that  I  have  described.  A  little  management  on  the  part  of  the 
Surgeon  will  enable  him  to  take  the  requisite  amount  of  covering  from 
the  outer  or  inner  parts,  by  inclining  the  point  or  the  heel  of  the  knife 
downwards,  as  the  case  may  require  ;  or  he  may  even  make  the  anterior 
flap  by  incision  from  without  inwards,  instead  of  by  transfixion. 

When  the  femur  is  entire  and  unbroken.  Assistant  ISTo.  2  uses  it  as  a 
lever,  bringing  the  lower  end  of  it  in  the  second  stage  of  the  operation 
downwards  and  outwards,  thus  causing  the  head  of  the  bone  to  press 
against  the  anterior  part  of  the  capsule,  and  to  start  out  with  a  peculiar 
sucking  noise  as  soon  as  that  is  opened.  Should,  however,  the  bone 
have  been  fractured  high  up,  this  movement  cannot  be  given  to  it ;  and 
then  the  Surgeon  must  grasp  the  upper  end  of  the  femur  below  the  tro¬ 
chanters,  so  as  to  steady  and  push  it  back  as  he  is  disarticulating  its 
head.  In  two  of  the  cases  in  which  I  have  amputated  at  the  hip-joint,  it 
has  been  necessary  to  do  this — in  one,  in  consequence  of  the  crush  of 
the  bone,  two  inches  below  the  trochanters,  by  a  railway  accident;  in  the 
other  in  consequence  of  its  spontaneous  fracture  at  the  junction  of  its 
upper  and  middle  thirds,  in  a  case  of  rapidly  growing  malignant  disease 
of  the  bone.  This  fractured  condition  of  the  femur  necessarily  makes 
the  operation  somewhat  more  difficult,  as  the  Surgeon  is  deprived  of  the 
long  lever  afforded  by  the  limb  in  its  sound  state,  by  which  the  head  is 
tilted  upwards  and  forwards,  and  the  capsule  put  on  the  stretch  so  as  to 
be  brought  directly  against  the  point  of  the  knife  as  it  is  drawn  across  it. 

In  amputation  of  the  hip-joint,  the  great  immediate  danger  to  be 
apprehended  is  excessive  hemorrhage,  the  incisions  being  made  so  high 
up  that  no  ordinary  tourniquet  can  be  applied.  B}'-  means  of  Lister’s 
compressor,  the  circulation  through  the  abdominal  aorta  maybe  arrested, 
and  thus  the  danger  obviated.  It  is  of  great  importance  to  perform  the 
operation  with  as  much  rapidity  as  possible,  and  the  disarticulation  ought 
to  be  effected  in  at  most  thirty  or  forty  seconds ;  and  it  may  be  done  in 
much  less  time  than  this.  The  arrest  of  the  hemorrhage  during  the 
operation  must  be  intrusted  to  an  assistant  who  can  be  fnily  relied  on. 
After  the  abdominal  compressor  has  been  applied,  and  the  flow  of  blood 
through  the  aorta  arrested,  his  business  should  be  to  compress  the  artery 
above  the  brim  of  the  pelvis,  and  then  to  follow  the  knife  in  the  first 
incision,  and,  as  the  anterior  flap  is  being  made,  slip  his  fingers  under 
it  and  grasp  it  firmly  above  and  below,  so  as  to  compress  the  femoral 
artery  in  it,  which  is  divided  as  the  knife  cuts  its  way  out  (Fig.  56.)  By 
grasping  the  flap  tightly,  there  will  be  but  little  risk  of  hemorrhage 
from  the  femoral  artery,  even  when  the  abdominal  aorta  has  not  been 
compressed  by  the  application  of  the  tourniquet ;  but  lest  this  should 
slip,  or  the  assistant  whose  duty  it  is  to  grasp  the  flap  by  any  chance 
should  fail  in  holding  it  properly,  it  may  be  well  to  direct  one  of  the 
assistants,  whose  business  it  is  to  steady  the  trunk,  to  have  his  thumb 
well  pressed  down  into  the  iliac  fossa,  so  as  to  compress  the  artery 
against  the  brim  of  the  pelvis.  As  the  posterior  flap  is  being  made,  the 


AMPUTATION  AT  THE  HIP-JOINT. 


91 


bleeding  from  the  gluteal  and  sciatic  vessels,  wliicli  is  often  very  free, 
may  be  arrested  by  two  assistants,  who  should  be  ready  to  cover  and 
compress  them  with  the  fingers  or  dry  sponges.  The  arteries  may  then 
be  ligatured  one  by  one,  as  the  assistant  raises  his  fingers  from  them. 

Fig.  5G. 


AraputatioQ  at  Hip-joint ;  Compression  of  Femoral  Artery  in  Anterior  Flap. 

If  he  have  good  hold  of  the  femoral,  the  vessels  in  the  posterior  flap 
may  be  tied  first ;  but  if  the  femoral  be  insecurely  held,  it  must  be  first 
tied.  The  femoral  arteries,  both  superficial  and  deep,  will  be  found  to 
be  cut  long,  and  to  project  from  the  muscles,  by  which  they  are  sur¬ 
rounded,  so  as  very  readily-  to  be  seized  by  the  fingers  or  forceps,  pulled 
out,  and  ligatured.  The  arteries  in  the  posterior  flap  and  on  the  inner 
side  of  the  joint  will  be  found  in  the  intermuscular  septa.  The  flaps  are 
to  be  brought  together  by  six  or  eight  sutures,  and  a  few  long  strips  of 
plaster.  The  turn  of  a  broad  bandage  may  then  be  passed  round  the 
abdomen,  and  the  end  brought  up  from  behind  under  the  stump  so  as  to 
support  the  flaps. 

Results. — The  mortality  after  amputation  at  the  hip-joint  is  neces¬ 
sarily  very  high.  This  we  should  naturally  expect  from  the  size  of  the 
part  removed  and  the  consequent  shock  to  the  S3^stem.  The  rate  of 
recoveiy  varies  greatl}^  according  to  the  condition  of  the  limb  that 
necessitates  the  operation.  Thus,  amputation  at  the  hip-joint  had  been 
performed,  so  far  as  I  can  ascertain  from  publislied  cases,  120  times  up 
to  the  year  1864;  of  these,  16  died.  But  in  47  instances  it  was  for 
injuiy:  of  these,  35  proved  fatal;  whilst  in  42  cases  in  which  it  was 
done  for  chronic  disease,  24  recovered,  and  onl}^  18  died. 

Primary  amputation  at  the  hip-joint  in  cases  of  severe  injury  of  the 
thigh,  gunshot  or  otherwise,  with  comminution  of  the  femur,  is  one  of 


92 


INFLAMMATION. 


the  most  fatal  operations  in  surgery.  In  all  the  12  cases  in  which  it 
was  clone  in  the  Crimea  it  proved  fatal ;  and  Legouest  has  collected  30 
cases  of  this  amputation  for  gunshot  injury,  in  all  of  which  the  opera¬ 
tion  terminated  in  death.  Indeed,  up  to  the  time  of  the  war  of  the 
rebellion  in  America,  there  was  no  authentic  instance  of  recovery  under 
these  circumstances.  But  in  an  elaborate  and  most  able  surgical  history 
of  that  great  war,  published  b}^  the  Surgeon-General,  19  cases  of  pri¬ 
mary  amputation  at  the  hip-joint  for  gunshot  injury  of  the  femur  are 
related.  Of  these,  11  died  from  the  immediate  shock  of  the  operation; 
5  died  between  the  2d  and  the  10th  day;  one,  a  man  28  years  of 
age,  wdio  had  amputation  at  the  hip  performed  b}^  Surgeon  Shippen 
seven  hours  after  the  receipt  of  his  wound,  was  in  perfect  health  four 
3'ears  after  the  operation ;  and  the  remaining  two  cases  had  been  cured, 
so  that  one  was  alive  and  well  two,  and  the  other  six  months,  after  the 
amputation. 

Intermediate  operations,  or  those  done  during  the  inflammatory 
period,  have  been  very  unsuccessful :  18  cases  that  occurred  in  the 
American  war  were  all  fatal. 

Secondary  amputation^  in  cases  of  attempted  preservation  of  the  limb 
after  severe  injuries  and  gunshot  wounds,  has  been  far  more  successful. 
Four  cases  in  which  J.  Roux  practised  it  in  the  French  campaign  of 
1859  in  Italy  all  recovered,  as  did  two  out  of  nine  in  which  it  was  prac¬ 
tised  in  America. 

Beaniputation  at  the  hip-joint  for  diseased  thigh-stumps  has  also  been 
a  successful  operation:  4  out  of  I  American  cases  recovered. 

Amputation  at  the  hip-joint  for  disease  of  the  femur  has  undoubtedly 
become  less  fatal  of  late  years  than  wms  formerly  the  case.  This  is 
doubtless  owing  partly  to  the  operation  being  submitted  to  at  an  earlier 
stage  of  the  disease  ;  to  a  better  selection  of  cases ;  possibly  to  improved 
methods  of  after-treatment ;  but  mainl}^,  I  believe,  to  the  influence  of 
anaesthetics,  by  which  the  shock  to  the  S3'stem  necessaril}^  resulting  from 
so  very  severe  a  mutilation  is  materially  lessened.  The  emplo3mient  of 
Lister’s  aorta  compressor  will  probably  still  further  reduce  the  mortalit3’ 
by  lessening  the  loss  of  blood,  and  thus  proportionately  diminishing 
those  risks  of  low  secondar3’  disease  that  are  induced  by  serious  hemor¬ 
rhage. 


CHAPTER  lY. 

INFLAMMATION. 

The  stud3"  of  the  inflammatory  process  is  one  of  the  most  difficult 
on  which  the  Surgeon  can  enter ;  but  the  labor  required  to  master  its 
details  is  wHl  bestowed,  inasmuch  as  an  acquaintance  with  its  nature, 
S3nnptoms,  and  progress,  gives  an  insight  into  a  greater  part  of  the  Sci¬ 
ence  of  Surgery.  The  management  of  inflammation  as  it  affects  different 
tissues  and  organs,  and  as  it  is  affected  by  various  concomitant  circum¬ 
stances,  comprises  a  great  part  of  the  duties  of  a  Surgeon.  The  Theory 
of  Inflammation  is  a  pureA  physiological  and  pathological  study ;  and, 
however  interesting  its  investigation  may  be,  3^et,  as  the  discussion  of 
this  subject  belongs  rather  to  the  domain  of  General  Pathology  than  to 


COXGESTIOX. 


93 


that  of  Practical  Siirgeiy,  it  cannot  consistenth'  be  entered  upon  here 
otherwise  than  in  mere  outline.  To  gain  a  full  acquaintance  with  the 
23resent  state  of  our  knowledge  regarding  the  intimate  nature,  origin, 
and  progress  of  the  inflammatory  23rocess,  the  student  must  consult  such 
books  as  the  works  of  Sir  James  Pnget,  and  of  Billroth  on  “Surgical 
Patholog}’,”  and  the  essa3’s  of  those  observers  in  this  country  and  abroad 
who  have  made  inflammation  the  object  of  special  investigation. 

Before  describing  inflammation,  it  will  be  necessaiy  to  notice  briefl^^ 
two  forms  of  disturbance  of  the  circulation  which,  wliile  thej^  always 
attend  the  inflammatoiy  process,  ma}’  exist  independenth'  of  it.  These 
are  the  two  forms  of  local  h3’per8emia,  known  as  Congestion  and  Deter¬ 
mination  of  Blood :  the  former  consisting  essentiall3'  in  retardation  in 
the  return  of  blood  from  a  part ;  the  latter,  in  increased  flow  of  blood 
to  a  part. 

Congestion  pla3’s  an  important  jDart  in  surgery' :  it  occasions  serious 
structural  changes,  and  ma3’  run  into  inflammation.  It  is  a  true  h3q3er- 
jemia  ;  in  it  we  find  not  onl3"  that  the  blood  is  greath’^  increased  in 
quantit3*,  but  that  it  circulates  languidl3’  through  the  i^art  and  is  of  a 
darker  color  than  natural.  The  arteries  are  at  most  of  their  normal 
size,  perhaps  even  contracted ;  the  veins  and  capillaries  are  greatly 
distended  b3"  the  SI0WI3"  moving  fluid.  When  the  circulation  in  the 
congested  jjart  becomes  completel3’  arrested,  stagnation  is  said  to  have 
occurred. 

Symptoms. — Congestion  of  an  external  part  ma3’  be  readily  recognized 
b3"  the  changes  it  induces  in  the  color,  the  feel,  the  size,  the  sensibilit3’, 
the  temperature,  and  the  functions  of  the  part.  The  color  of  a  con¬ 
gested  part  ranges  from  puiqflish  red  to  a  dusk3^  brown  ;  its  size  is 
increased ;  it  feels  soft,  and  j)its  under  the  pressure  of  the  finger.  The 
j^atient  is  often  conscious  of  a  heav3',  dull,  aching  sensation  in  it,  scarcely 
amounting  to  j^ain,  but  3^et  attended  with  uneasiness.  The  temperature 
is  never  above,  but  often  below,  the  natural  standard,  and  the  functions 
are  lessened  in  activity. 

The  existence  of  congestion  in  an  internal  organ  ma3'^  be  ascertained 
b3’  finding  its  size  increased,  and  its  functions  modified,  with  a  sensation 
of  weight  in  it.  The  s3'm23toms  of  internal  congestion  are  often,  however, 
veiy  obscure. 

Effects. — These  are  of  much  surgical  importance.  The  first  change  that 
usuall3'  takes  place  is  an  effort  in  the  vessels  of  the  part  to  relieve  them¬ 
selves,  ly  a  transudation  of  the  more  wateiy  constituents  of  the  blood 
into  the  surrounding  areolar  tissue.  Hence  the  interspaces  of  this  tissue 
are  distended  ly  the  eflfused  fluid,  giving  rise  to  oedema. 

If  the  turgidit3''  of  the  vessels  be  great,  and  their  walls  at  the  same 
time  weakened,  riq^ture  will  occur,  and  hemorrhage  to  the  surface,  or 
into  the  substance  of  the  ])art,  will  ensue. 

In  consequence  of  the  infiltration  of  the  areolar  tissue,  softening  takes 
jflace,  nutrition  becomes  less  and  less  ^^erfecth'  jjerformed,  and  ulceration 
at  last  occurs.  These  changes  we  not  unfrequentW  see  in  the  integuments 
of  the  legs  of  old  j^eoifle.  In  other  cases,  the  vessels  becoming  perma- 
nenth"  dilated,  the  i^art  assumes  habitualh'  a  redder  or  darker  tint, 
becomes  swollen,  and,  if  it  be  a  mucous  surface,  it  ma3"  be  roughened 
and  i^apillated,  as  is  often  observed  in  a  congested  conjunctiva. 

Causes. — Congestion  is  al'wa3’s  a  jDassive  and  mechanical  condition  : 
and  hence  the  term  “  active  congestion”  is  not  a  proj^er  one.  What  has 
been  described  as  active  congestion  is  merely  a  variet3’  of  inflammation. 

The  causes  of  congestion,  alwa3’s  mechanical,  ma3'be  divided  into  two 


94 


INFLAMMATION. 


great  classes,  which  we  often  find  conjoined  :  1.  Those  causes  that  act  hy 
obstructing  the  return  of  tlie  venous  blood  ;  2.  Those  that  act  b}'  enfee¬ 
bling  the  walls  of  the  capillaries  and  veins,  so  that  the}’’  are  no  longer 
able  to  withstand  the  outward  pressure  of  the  contained  blood. 

1.  Amongst  the  first  set  of  causes,  maj'  be  specified  any  condition 
that  directly  and  immediate!}"  interferes  with  the  proper  return  of  blood 
through  a  A"ein ;  in  this  way  the  pressure  of  a  tumor  upon  such  a  vessel 
produces  congestion  of  the  part  from  which  it  carries  off  the  blood. 

Venous  obstruction  does  not  always  act  in  so  direct  a  manner  as  this ; 
for  it  not  unfrequently  happens,  that  obstruction  to  the  return  of  blood 
from  one  organ  will  be  attended  by  a  congestive  condition  of  the  vessels 
in  a  distant  one.  Thus  we  find  some  forms  of  congestion  of  the  eye-ball 
connected  with  obstruction  in  the  branches  of  the  portal  veins. 

The  long-continued  dependent  position  of  a  part  may  occasion  its 
congestion  b}"  the  blood  mechanically  gravitating  into  it,  and  overcoming, 
by  the  pressure  thus  brought  to  bear  upon  the  vessels,  the  onward 
movement  of  the  fluid  within  them.  Tims  we  see  cono;estion  of  the 
leo'S  from  lono-continued  standino-  •  of  the  hemorrhoidal  veins  from  an 

O  ^  0  7 

habitually  sedentary  life  ;  and  of  the  posterior  part  of  the  lungs  of  those 
who  have  been  long  confined  to  the  recumbent  position. 

2.  Amongst  the  most  common  causes  of  congestion  that  act  b}"  enfee¬ 
bling  the  vessels,  we  find  the  debility  of  old  age,  acting  partly  by  lessen¬ 
ing  the  tone  of  the  vascular  sj’stein  generally,  and  partly  b}"  inducing  a 
diminution  of  the  propulsive  power  of  the  heart.  So  also  cold,  by 
lessening  the  vitalit}*  and  retarding  the  circulation  of  a  part,  produces 
congestion  in  it.  Certain  typhoid  or  adynamic  states  of  the  S3'stem 
favor  the  occurrence  of  congestion  in  the  more  dependent  parts.  And, 
lastly,  inflammation  ma}"  terminate  in  this  condition. 

The  obstructive  causes  are  especially  apt  to  induce  congestion  when 
the}"  occur  in  connection  with  a  feeble  condition  of  the  vascular  system. 

Ti'eatment. — The  treatment  of  congestion  has  strict  reference  to  its 
cause. 

The  first  indication  consists  in  the  removal  of  any  source  of  obstruc¬ 
tion  to  the  return  of  blood  from  the  part,  as  by  unloosening  a  ligature, 
or  elevating  a  part  that  has  been  too  long  dependent :  or,,  less  directly, 
as  in  the  case  of  many  internal  congestions,  by  restoring  the  freedom  of 
the  circulation  through  the  larger  viscera.  Thus  a  congested  eve  or 
pile  may  be  relieved  by  the  removal  of  hepatic  or  portal  obstruction. 

The  next  indication  consists  in  lessening  the  quantity  of  blood  in  the 
congested  part.  The  mere  removal  of  the  obstructing  cause  may  effect 
this.  In  other  cases,  the  direct  removal  of  the  blood  by  scarification,  as 
in  a  congested  conjunctiva,  or  by  leeches,  as  around  a  turgid  pile,  affords 
immediate  relief.  In  some  parts,  again,  the  judicious  application  of  a 
bandage  will  prevent  or  remove  congestion.  With  this  view,  the  hand 
and  arm  are  bandaged  before  the  apparatus  for  a  fractured  clavicle  is 
applied:  and  in  varix  the  leg  is  supported  by  an  elastic  stocking,  to 
lessen  the  pressure  of  blood  in  the  dilated  veins. 

The  third  indication  in  the  treatment  of  congestion  consists  in  con¬ 
stringing  the  dilated  vessels  by  the  direct  application  of  an  astringent  to 
them  ;  thus  we  habitually  apply  nitrate  of  silver  to  a  congested  mucous 
membrane,  and  cold  douches  to  many  external  forms  of  the  disease. 

Determination. — We  haA'e  already  seen  that  congestion  essentially 
consists  in  an  impeded  return  of  the  venous  blood  from  a  part.  In 
determination^  the  condition  is  reversed ;  arterial  blood  is  sent  in 
increased  quantity  to  a  part,  and  circulates  through  it  with  great  rapidity. 


DETERMINATION. 


95 


This  condition,  which  is  often  called  “increased  action,”  differs  thus 
from  congestion  in  every  respect  except  that  of  the  blood  being  in 
excess. 

Determination  of  blood  is  a  vital  process,  often  ver}"  transitory,  and 
frequently  occurs  as  a  normal  action  in  those  conditions  of  the  system 
in  which,  for  temporal*}'  purposes,  an  increased  afflux  of  blood  is  called 
for  by  particular  organs.  The  enlargement  of  the  mamma  before  lacta¬ 
tion,  and  the  turgor  of  the  erectile  tissues,  afford  familiar  illustrations. 

All  increased  local  supply  of  blood  lies  at  the  bottom  of  most  surgical 
processes;  few  important  surgical  actions  taking  place  without  it.  No 
process  by  which  the  separation  of  dead  parts  is  effected,  or  by  which 
the  repair  of  wounds  or  ulcers  is  carried  out,  can  occur  without  it.  Every 
tissue  is  susceptible  of  it;  and  the  Surgeon  often  excites  it  intentionally 
as  one  of  the  most  efficient  of  his  therapeutic  means.  In  these  circum¬ 
stances,  therefore,  it  cannot  be  considered  a  disease. 

"When  determination  of  blood  becomes  chronic  or  continued,  it  may 
lead  to  such  changes  in  the  appearance,  structure,  and  functions  of  a  part 
as  materially  modify  its  nutritive  and  secretory  activity ;  and  then  it 
becomes  truly  a  disease.  In  these  circumstances,  the  part  is  often  said 
to  be  in  a  state  of  “  chronic  irritation.” 

Symptoms. — The  symptoms  of  determination  of  blood  are  those  that 
we  should  expect  to  result  from  an  increased  quantity  of  blood  rushing 
with  increased  velocity  through  the  affected  textures.  There  are  redness 
of  a  bright  scarlet  hue,  swelling  from  turgescence  of  the  vessels,  heat 
cognizable  to  the  Surgeon  as  well  as  to  the  patient,  a  feeling  of  fulness 
and  of  throbbing,  with  an  increase  in  the  quantity  of  the  secretions  of 
the  part ;  in  fact,  all  those  symptoms  that  characterize  inflammation  in 
its  milder  forms,  but  in  a  minor  degree  and  of  a  less  persistent  character. 

Effects. — The  effects  of  determination,  when  acute,  consist  either  in 
rupture  of  the  affected  vessels,  and  a  natural  relief  by  the  hemorrhage 
which  ensues,  as  may  happen  in  piles  after  a  dose  of  aloes  has  been 
given  ;  or,  if  a  free  surface  or  a  gland  be  affected,  in  the  pouring  forth 
of  the  secretions  of  the  part,  considerably  augmented  in  quantity  and 
perhaps  deviating  somewhat  from  their  normal  character,  as  in  lachryma- 
tion  after  the  introduction  of  a  grain  of  snuff  into  the  eye.  When  this 
effusion  occurs  within  shut  serous  sacs,  dropsical  accumulations  may 
ensue. 

The  more  remote  effects  of  chronic  determination  of  blood  to  a  part 
consist  in  permanently  increasing  its  nutritive  activity,  and  thus  leading 
to  induration  and  hypertrophy.  Or,  determination  of  blood  may  result 
in  true  inflammation. 

Causes. — The  causes  of  determination  of  blood  are  threefold. 

First,  an  external  irritant  directly  applied  to  a  part  will  induce  it,  as 
when  a  grain  of  dust  is  blown  upon  the  conjunctiva.  Secondly,  internal 
irritation,  as  increased  use  of  a  part,  or  the  necessity  for  its  use,  will 
determine  an  increased  flow  of  blood  to  it.  Thus,  using  the  eyes  much 
in  microscopic  investigations  may  produce  redness,  w'atering,  and  irrita¬ 
tion  of  those  organs.  To  this  class  of  causes  may  also  be  referred  the 
various  forms  of  normal  determination,  such  as  erection,  or  the  enlarge¬ 
ment  of  the  mamma  in  pregnancy.  Thirdly,  there  may  be  a  repercussion 
of  blood  from  one  part  to  another:  as  when  the  application  of  cold  to 
the  surface  produces  an  increased  afflux  of  blood  to  an  internal  organ. 

The  vaso-motor  influence  of  the  sympathetic  nerve  exercises  a  marked 
control  over  the  circulation  of  a  part :  and  the  relaxation  of  this  control 
is  attended  by  determination  of  blood.  Thus,  when  the  sympathetic 


96 


ACUTE  INFLAMMATION. 


nerve  in  the  neck  of  a  clog  or  rabbit  is  divided,  the  arteries  in  the  cor¬ 
responding  side  of  the  head  become  dilated,  a  greater  afflux  of  blood 
takes  place,  reddening  of  the  skin  and  mucous  surfaces  occurs,  and  the 
temperature  is  increased — all  these  being  evidences  of  the  determination 
of  blood  to  the  affected  side.  Whether,  and  how  far,  an  interference 
with  the  regulating  power  of  the  vaso-motor  nerves  has  an  influence  in 
the  causes  of  determination  which  have  been  noticed  above,  is  a  question 
of  pathology  beyond  the  scope  of  this  book. 

The  Treatment  of  determination  of  blood  is  nearly  identical  with  that 
of  the  milder  forms  of  inflammation,  of  which  we  shall  have  to  speak 
hereafter. 


ACUTE  INFLAMMATION. 

The  forms  of  local  h3^pergemia — Congestion  and  Determination — 
described  above,  are  essentiallj'  characterized  by  an  increase  in  the 
quantit^^  of  blood  in  the  part.  In  congestion,  the  quantity  of  blood  is 
increased,  but  its  motion  is  lessened:  in  determination,  there  is  an 
enlargement  of  the  vessels,  and  an  accelerated  flow  through  them  of  an 
increased  quantity  of  blood.  In  Inflammation,  both  these  conditions 
are  present ;  but  there  are  also  certain  phenomena  on  the  part  of  the 
vessels,  and  especiall^^  of  the  blood  and  its  components,  which  give  to 
inflammation  its  distinctive  characters. 

The  phenomena  of  inflammation,  as  studied  in  the  transparent  tissues 
of  some  of  the  lower  animals,  such  as  the  wing  of  the  bat,  or  the  web  of 
a  frog’s  foot,  or  the  mesentery  of  the  same  animal,  are  as  follows.  On 
the  application  of  an  irritant,  such  as  the  point  of  a  needle  or  a  weak 
solution  of  salt  or  cold  water,  there  is  produced  momentary  contraction 
of  the  small  arteries,  followed  b^^  their  dilatation  ;  the  veins  also  become 
dilated ;  the  flow  of  blood,  at  first  accelerated,  becomes  retarded ;  and 
stasis  or  stagnation  occurs  at  points,  commencing  in  the  capillaries,  and 
extending  to  the  veins  and  arteries.  At  the  points  of  stasis  there  is  an 
aggregation  of  the  red  and  the  white  corpuscles  of  the  blood,  which 
appear  to  block  up  the  vessels ;  the  red  corpuscles,  according  to  Cohii- 
heim,  occupying  the  arteries,  and  the  white  ones  the  veins.  Around  the 
centre  of  stagnation  there  is  a  retarded  flow  of  blood,  in  which  the  cor¬ 
puscles  are  seen  to  move  languidly ;  and  be^^ond  this  there  is  that 
increased  rush  of  an  increased  quantity  of  blood  which  characterizes 
determination. 

These  are  the  general  phenomena  presented  b^"  an  inflamed  part  wdien 
studied  under  the  microscope.  In  order  to  become  acquainted  with  the 
elements  of  this  process,  we  must  analj^ze  the  condition  of  (1)  the  Ves¬ 
sels,  and  (2)  the  Blood, 

1.  Vessels. — The  observations  of  Wharton  Jones  on  the  frog’s  foot,  of 
Paget  on  the  bat’s  wing,  of  Cohnheim  on  the  mesentery  of  the  frog, 
and  other  similar  investigations,  agree  in  showing  that  one  of  the  initial 
phenomena  of  inflammation  is  dilatation  of  the  small  vessels.  But 
whether  this  dilatation  be  primary  or  not,  would  appear  to  depend 
greatly  on  the  nature  of  the  stimulant  applied,  and  perhaps  on  other 
circumstances  that  we  cannot  readil}^  appreciate.  Sometimes  the  en¬ 
largement  is  seen  to  be  preceded  by  temporary  contraction ;  as  when 
the  part  is  irritated  with  the  point  of  a  needle,  or  by  the  application  of 
a  weak  solution  of  salt,  or  cold  water,  or  spirit  of  wine ;  while  dilatation 
without  an}”  appreciable  previous  contraction  is  at  once  produced  b}'  the 
application  of  acetic  acid  or  capsicum  (Paget),  vinum  opii,  or  a  strong 


ACUTE  INFLAMMATION. 


97 


solution  of  salt  or  sulphate  of  copper  (Wharton  Jones),  or  h}^  the  mere 
exposure  of  the  frog’s  inesenteiy  to  the  air  (Cohnheim).  The  solid  sul¬ 
phate  of  copper  produces  speedy,  complete,  and  permanent  contraction. 

The  dilatation  affects  not  only  the  small  arteries  in  the  immediate 
vicinit}"  of  the  inflamed  part,  hut  those  also  at  a  distance  which  lead  to 
it :  tliis  is  shown  by  the  increased  strength  and  force  of  the  pulsation 
in  them,  consequent  on  the  loss  of  power  to  resist  by  their  tonicity  the 
heart’s  action.  This  may  be  readily  observed  in  the  pulsation  of  the 
digital  arteries  in  a  case  of  whitlow.  That  the  rapidity  of  the  current 
of  blood  from  as  well  as  to  the  inflamed  part  is  increased,  is  proved  by 
the  observation  of  Lawrence,  who  found  that  in  bleeding  a  patient,  with 
whitlow  on  one  hand,  in  both  arms,  more  blood  flowed  from  the  inflamed 
than  from  the  sound  limb  in  the  same  space  of  time. 

In  consequence  of  the  dilatation  of  the  smaller  arteries  and  capillaries 
of  the  part,  red  corpuscles  are  admitted  in  crowds  where  single  files 
could  only  penetrate  before.  In  this  wa}",  for  instance,  the  surface  of  the 
conjunctiva  ina}''  in  a  few  hours  be  brightly  reddened,  not  by  the  forma¬ 
tion  of  new  vessels,  but  b}^  dilatation  and  accumulation  of  blood  in  pre¬ 
viously  existing  ones. 

Besides  undergoing  dilatation,  the  arteries  become  elongated,  tortuous, 
and  waved,  increasing  in  length  as  well  as  in  diameter.  The  German 
pathologists — Kolliker,  Hasse,  and  Bruch,  whose  views  are  confirmed 
by  Paget  and  Wharton  Jones — have  observed  that  the  arteries  of  the 
inflamed  part  have  a  tendency  to  become  dilated  at  points,  so  as  to  pre¬ 
sent  small  varicose  or  aneurismal  pouches  projecting  from  their  walls,  or 
fusiform  dilatations  of  their  whole  diameter.  The  changes  would  appear 
to  arise  from  one  of  two  causes :  either  that  the  vessel  is  constricted  at 
points  between  which  it  maintains  its  normal  width,  and  thus  that  the 
dilatation  is  apparent  and  not  real ;  or,  that  it  is  actuall}'’  dilated  where 
it  appears  to  be  so.  This  appearance  of  partial  dilatation,  according  to 
Yirchow,  is  not  confined  to  inflammation. 

2.  Blood. — This  fluid  in  inflammation  undergoes  important  changes, 
both  in  the  liquor  sanguinis  and  the  corpuscles. 

In  the  liquor  sanguinis  the  proportion  of  albumen  and  of  saline  matter 
is  somewhat  below  the  natural  standard,  wLile  that  of  the  water  is 
increased.  The  increased  thinness  of  the  blood  was  long  ago  pointed 
out  by  Hewson.  The  amount  of  spontaneously  coagulating  material — 
or  fibrin — is  increased  ;  according  to  Andral  and  Gavarret,  it  may  rise 
from  per  1000  to  10  per  1000. 

When  inflammatory  blood  is  drawn  from  the  body,  it  coagulates  more 
slowly  than  healthy  blood ;  the  coagulura  also  is  harder  and  smaller, 
and  the  quantity  of  serum  apparently  greater.  The  surface  of  the 
coagulum  is  commonly  covered  by  a  tough  layer  of  yellow  fibrinous 
matter,  the  huffy  coat ;  and  its  upper  surface  is  depressed  in  the  centre, 
having  elevated  edges,  being  cupped.,  as  it  is  usually  termed.  This 
“  buff”  and  “  cup”  was  formerly  much  used  as  a  guide  in  estimating  the 
intensity  of  the  inflammation;  it  has,  how^ever,  been  shown  that  buff 
ma}’  occur  in  certain  conditions  of  the  system,  as  in  plethora,  or  preg¬ 
nancy,  or  after  exercise,  without  the  occurrence  of  inflammation ;  and 
that  the  tissue  affected,  rather  than  the  severity  of  the  inflammation, 
influences  its  quantity ;  thus,  it  is  greatest  when  the  fibrous  or  serous 
tissues,  and  least  when  the  mucous  or  tegumentary,  are  inflamed.  The 
cupped  shape  of  the  clot  is  in  some  degree  dependent  on  the  shape  of 
the  vessel  into  which  the  blood  is  received,  being  most  evident  when  it 
is  rather  narrow  and  deep. 

VOL.  I _ 7 


98 


INFLAMMATION. 


The  blood-corpuscles^  both  red  and  white,  have  been  already  described 
as  becoming  collected  in  great  number  in  the  vessels  of  the  inflamed 
part.  Does  this  indicate  an  increase  of  both  or  either  of  these  in  the 
general  mass  of  the  blood  ?  The  red  particles,  according  to  Andral  and 
Gavarret,  are  increased  in  quantit}^  in  the  early  stages  of  inflammation ; 
but  as  the  disease  advances  they  fall  below  the  natural  standard,  as 
Wharton  Jones  and  Simon  have  pointed  out.  They  manifest  increased 
adhesiveness,  and  a  tendenc}'^  to  aggregation  into  clusters  b}^  cohesion 
of  their  flat  surfaces,  in  blood  removed  from  the  body  as  well  as  in  that 
within  the  vessels.  As  to  the  white  corpuscles,  Dr.  C.  J.  B.  Williams 
described  these  in  1842  as  being  present  in  augmented  numbers  in  the 
vessels  of  the  inflamed  part :  whether,  however,  the  amount  of  them  in 
the  blood  is  really  increased  in  inflammation,  is  doubted  by  Paget,  Simon, 
and  others.  That  an  increase  of  the  white  corpuscles  is  not  an  abso¬ 
lutely  distinctive  characteristic  of  inflammation,  seems  indicated  by 
their  excessive  formation  in  leucocythsemia. 

Regarding  the  behavior  of  the  corpuscles  in  the  vessels  of  the 
inflamed  part,  some  very  interesting  observations  have  been  made  in 
recent  years.  As  long  ago  as  1845,  Dr.  W.  Addison  described  a  passage 
of  the  white  corpuscles  out  of  the  vessels.  This  observation  was  con¬ 
firmed  in  the  next  year  by  Dr.  Augustus  Waller,  but  appears  to  have 
been  but  little  noticed  until  186Y,  when  Cohnheim,  of  Berlin,  published 
an  account  of  observations,  in  which  he  had  seen  both  the  red  and  the 
white  corpuscles  escaping  through  the  coats  of  the  .  vessels  without 
rupture  of  these. 

The  passage  of  the  red  blood-corpuscles  through  the  walls  of  the 
capillaries  may  be  well  seen,  Cohnheim  says,  in  the  web  of  the  frog’s 
foot,  when  congestion  has  been  produced  by  tying  the  femoral  vein. 
Stasis  in  some  of  the  capillaries  occurs  in  about  a  quarter  of  an  hour ; 
and  in  less  than  an  hour  there  are  seen  irregular  projections  from  the  walls 
of  the  vessels.  These  projections  go  on  increasing,  and  some  of  them 
soon  separate  themselves,  and  may  be  seen  in  the  adjacent  tissue  as  un¬ 
mistakable  red  corpuscles.  Strieker,  wdio,  with  Kolliker,  Sharpey,  Bill¬ 
roth,  Bastian,  and  others,  confirms  Cohnheim’s  observations,  says  that 
the  injection  of  10  per  cent,  solution  of  chloride  of  sodium  favors  the 
passage  outwards  of  the  red  corpuscles  so  much  as  to  cause  hemorrhagic 
maculae.  Cohnheim  believes  that  the  amount  of  red  corpuscles  which 
thus  escape,  varies  with  the  number  of  capillaries  possessed  by  tlie 
inflamed  organ  ;  being  greater,  for  instance,  in  pneumonia  than  in  inflam¬ 
mation  of  the  mesentery. 

The  passage  of  the  white  corpuscles  through  the  walls  of  the  vessel 
is  described  as  taking  place  in  the  following  manner.  If  the  wdiite  cor¬ 
puscles  be  carefully  watched,  some  of  them  may  be  seen,  after  a  short 
time,  to  pass  through  the  wall  of  the  vein  against  which  they  have  been 
collected.  This  passage  through  is  accompanied  by  striking  amoeba-like 
changes  of  form.  A  small  knob  may  be  seen,  for  instance,  outside  the 
w^all,  opposite  to  a  spot  where  a  white  corpuscle  is  clinging  to  it  wdthin. 
The  knob  outside  grows  larger  and  larger,  while  the  corpuscle  inside 
becomes  smaller,  till  it  vanishes,  having  passed  altogether  through  the 
wall.  In  the  capillaries,  both  red  and  w^hite  corpuscles  pass  out :  in  the 
veins  only  the  latter.  We  shall  have  to  refer  again  to  this  migration  of 
the  white  corpuscles  when  we  come  to  speak  of  suppuration,  in  which 
process  it  appears  to  bear  an  important  part. 

Regarding  the  manner  in  which  the  corpuscles  escape  through  the 
unruptured  walls  of  the  vessels,  there  is  not  as  yet  an  agreement  among 


LOCAL  SIGNS. 


99 


those  who  admit  the  occurrence  of  the  migration.  Cohnheim,  for  instance, 
says  that  they  pass  bj"  the  amoebiform  movements  through  stomata  be¬ 
tween  the  epithelial  cells  of  wdiich  the  vascular  wall  is  composed,  and 
that  the  passage  out  is  aided  by  pressure  :  Strieker  and  Prussak  describe 
the  process  as  effected  by  an  “  active  state”  of  the  wall  of  the  vessel, 
w^hich  consists  of  a  homogeneous  extensile  protoplasm  ;  Bastin  ascribes 
the  migration  to  amoeboid  movements  of  the  corpuscles,  such  as  were 
described  in  1863  by  Recklinghausen;  and  Billroth  conjectures  that  the 
emigration  of  the  colorless  corpuscles  may  be  facilitated  by  softening  of 
the  vascular  walls. 

These  are  the  principal  changes  met  with  in  the  vessels  and  blood  of 
the  affected  part.  The  nerves  and  the  other  tissues  have  doubtless  an 
important  influence,  the  precise  nature  and  extent  of  which  are  not  3^et 
thoroughl}"  understood.  As  Lister  has  observed,  the  tissues  of  the  part 
are  in  a  state  of  impaired  nutrition  and  diminished  functional  activity ; 
the}’’  “have  suffered  a  diminution  of  power  to  discharge ‘the  offices 
peculiar  to  them  as  components  of  the  healthy  animal  frame.” 

In  what  relation,  as  to  order,  do  the  phenomena  of  inflammation  stand 
to  each  other  ?  Strieker,  who  has  ably  investigated  this  matter  by  expe¬ 
riment,  believes  that  the  preliminary  step  is  a  morbid  influence  on  the 
vessels,  either  direct  or  through  the  vascular  nerves,  originating  within 
or  without  the  organism;  and  that  there  then  follow:  1.  Local  disturb¬ 
ance  of  circulation ;  2.  Increased  exudation  of  the  fluid  and  formed 
elements  (corpuscles)  of  the  blood  ;  3.  Disturbed  nutrition  of  the  part ; 
4.  Increase  of  cellular  elements.  This  brings  us  to  the  stage  of  suppu¬ 
ration,  of  wdiich  we  shall  have  to  speak  hereafter. 

Symptoms  of  Inflammation. — These  are  local  and  constitutional. 
In  order  that  they  should  occur,  so  as  to  establish  the  existence  of  the 
inflammatory  process,  it  is  necessary  that  the  actions  constituting  it  con¬ 
tinue  for  some  length  of  time;  as  they  gradually  pass  from  simple 
h3’per0emia  into  inflammation,  it  is  diflicult  to  sa}",  except  b}^  the  persist¬ 
ence  and  intensity  of  the  S3^mptoms,  that  this  process  has  actually 
commenced. 

The  Local  Signs  of  inflammation  ma}^  be  referred  to  five  heads:  viz., 
1.  Alteration  in  Color ;  '2,.  Alteration  in  Size  ;  3.  Modification  of  Sensa¬ 
tion ;  4.  Increase  of  Temperature  ;  and  5.  Modification  of  Function  of 
the  Part  Affected.  Certain  of  these  conditions  ma}^  occur  separately,  or 
two  or  more  maybe  associated  together,  without  the  existence  of  inflam¬ 
mation  ;  but  it  is  the  peculiar  grouping  together  of  them  all  that  most 
distinctly  characterizes  the  presence  of  this  pathological  condition. 
The  relative  intensity  of  these  changes  varies  greatly,  according  to  the 
tissue  which  is  the  seat  of  the  inflammation;  thus,  in  inflammation  of 
mucous  membranes  and  the  skin,  the  alteration  in  color  is  most  marked; 
in  inflammation  of  the  areolar  tissue,  the  change  in  size  alwa3^s  attracts 
special  attention;  and  when  a  fibrous  tissue  is  inflamed,  its  sensibility 
becomes  greatl}”  increased.  Moreover,  one  or  other  of  these  signs  may 
be  absent,  especially  pain  and  heat. 

1.  Alteration  of  Color  is  an  invariable  and  one  of  the  earliest  and  most 
striking  local  signs  of  inflammation ;  parts  that  are  naturall}"  perfectly 
pale,  as  the  ocular  conjunctiva,  assuming  the  most  vivid  crimson  color 
when  inflamed.  Some  parts,  though  they  change  in  color,  do  not  become 
red.  Thus,  the  iris,  when  inflamed,  assumes  a  gra3ish  or  brownish  tinge ; 
and  the  mucous  membrane  of  the  bladder,  and  a  portion  of  intestine,  often 
become  slate-colored.  The  redness  of  inflammation  varies  from  a  brio-ht 
crimson  to  a  dull  purple,  the  tint  depending  greatl}^  upon  the  state  of  the 


100 


INFLAMMATION. 


constitution,  and  upon  the  presence  of  more  or  less  congestion.  The 
duller  and  darker  the  tint,  the  more  local  congestion  or  constitutional 
depression  do  we  usually  find.  The  redness  is  evidently  due,  in  the 
earlier  stages  of  the  disease,  to  the  dilatation  of  the  vessels,  and  the 
increased  admission  of  new  red  corpuscles  by  which  thej^  are  distended. 
In  some  low  or  asthenic  forms  of  the  disease,  the  coloring  matter  of  the 
blood  appears  to  undergo  changes  that  allow  its  ready  transudation 
through  the  walls  of  the  vessels,  or  perhaps  there  is  an  increased  migra¬ 
tion  of  the  red  corpuscles  ;  and  in  some  chronic  cases  the  vascularization 
of  the  products  of  inflammation  tends  to  render  the  coloration  more 
permanent. 

2.  Alteration  in  Size. — In  the  early  stages,  this  is  due  to  the  dilatation 
of  the  vessels ;  in  the  more  advanced  conditions,  chiefly  to  the  occurrence 
of  effusions  of  various  kinds,  of  which  we  shall  speak  in  another  place. 

The  swelling  varies  greatly  in  different  localities.  It  is  greatest  in 
loose  textures,  and  least  in  those  which  are  firm  and  dense.  Thus,  for 
instance,  in  inflammation  of  the  areolar  tissue  of  the  scrotum,  the  swell¬ 
ing  is  much  greater  than  in  the  same  disease  affecting  the  testes.  The 
inflammation  of  the  conjunctiva  occasions  great  swelling,  that  of  the 
sclerotic  but  little.  If  the  inflammation  becomes  chronic,  the  swelling 
may  terminate  in  permanent  hypertrophy,  or  thickening,  as  will  hereafter 
be  described. 

3.  Modification  of  the  Sensibility  of  the  Part^  owing  partlj^  to  increased 
sensibility  of  the  nerves,  but  chiefly  to  the  pressure  exercised  on  their 
terminal  branches  by  the  dilated  bloodvessels,  manifests  itself  by  the 
occurrence  of  pain,  or  by  some  alteration  in  the  special  nervous  sensi¬ 
bility  of  an  organ  :  thus,  in  the  eye,  b}^  the  patient  perceiving  flashes  of 
light,  and  in  the  ear,  b}^  noises  of  various  kinds ;  in  the  bladder,  by  a 
constant  desire  to  expel  the  urine  ;  and  in  inflammation  of  the  kidney, 
by  a  desire  to  urinate. 

Pain  is  one  of  the  most  prominent  symptoms  of  inflammation,  and  its 
existence  serves  an  useful  purpose  b}’  preventing  the  patient  from  using 
or  moving  the  inflamed  part.  The  intensity  of  the  pain  depends  more 
upon  the  structure  affected  than  on  the  violence  of  the  inflammation, 
being,  as  a  general  rule,  greater  in  proportion  as  the  structure  affected 
is  incapable  of  yielding  to  the  pressure  exercised  on  it  by  the  dilated 
vessels  and  the  effused  matters.  Hence,  in  general,  the  intensity  of  the 
pain  is  in  the  inverse  ratio  of  the  swelling  of  the  part.  Thus,  the  pain 
of  inflamed  bone  or  fibrous  tissue  is  excessive ;  that  of  areolar  membrane 
trifling.  In  eiysipelas  of  the  scalp,  most  pain  is  experienced  in  the  ears  ; 
the  pain  of  an  inflamed  sclerotic  is  far  greater  tlian  that  of  a  conjunctiva 
similarl}’’  affected.  In  some  forms  of  inflammation  pain  can  scarcely  be 
said  to  exist,  though  the  disease  ma}^  assume  the  most  destructive  form. 
Thus,  in  certain  inflammatory  affections  of  the  throat  and  of  the  peri¬ 
toneum,  there  is  little  or  no  pain. 

The  character  of  pain  varies  according  to  the  seat  of  the  inflammation. 
Thus,  when  mucous  membranes  suffer,  it  is  often  of  a  grittj',  itching,  or 
burning  character,  as  in  conjunctivitis ;  when  the  serous  membranes  of 
the  chest  or  abdomen  are  attacked,  it  is  lancinating  or  stabbing ;  aching 
in  bones  ;  throbbing  when  pus  is  about  to  form  ;  sickening  when  the  testis 
is  affected.  Inflammatory  pain  is  always  increased  on  pressure ;  when 
it  is  principally  produced  by  pressure,  the  part  is  said  to  be  tender.  This 
tenderness  is  of  great  service  in  a  diagnostic  point  of  view ;  it  may  be 
elicited  by  direct  pressure  upon  the  part,  as  by  squeezing  an  inflamed 
testis,  or  by  pressing  two  surfaces  together,  as  in  an  inflamed  joint.  In 


CONSTITUTIONAL  SYMPTOMS.  lOl 

inflammatory  pain,  especially  of  osseous  and  fibrous  tissues,  there  is 
very  commonly  nocturnal  exacerbation. 

It  is  important  to  bear  in  mind  that  inflammatory  pain  is  often  not 
seated  merely  in  the  part  affected,  but  radiates  extensively  along  the 
course  of  the  nerves,  the  terminal  branches  of  which  are  implicated  to  a 
limited  extent  perhaps.  Thus,  in  inflammation  of  the  testis  there  is  pain 
in  the  loins  and  groins.  In  deep-seated  ophthalmia  there  may  be  exqui¬ 
site  pain  along  the  branches  of  the  fifth  nerve  over  the  whole  side  of  the 
head  or  face,  in  consequence  of  the  ciliary  branches  of  the  nasal,  which 
are  distributed  to  the  iris  and  choroid,  becoming  compressed  or  stretched. 

4.  The  Temperature  of  an  inflamed  part  usualh’’ rises  above  its  normal 
standard.  Hunter  has,  however,  remarked  that  it  does  not  increase  above 
that  of  the  left  ventricle  ;  thus,  in  a  case  of  h3’^drocele,  he  found  the  tunica 
vaginalis  at  92'^  Fahr.  before  inflammation  had  been  excited  in  it,  and 
at  98j°  after  it  had  been  set  up.  In  a  case  of  extravasation  of  urine, 
with  severe  inflammation,  I  found  the  temperature  in  the  incision  made 
in  the  perineum  98°  Fahr.  Simon,  from  experiments  with  a  thermo¬ 
electric  apparatus,  has  found  :  “1.  That  the  arterial  blood  supplied  to  an 
inflamed  limb  is  less  warm  than  the  focus  of  inflammation  itself ;  2.  That 
the  venous  blood  returning  from  an  inflamed  limb,  though  less  warm  than 
the  focus  of  inflammation,  is  warmer  than  the  arterial  blood  supplied  to 
the  limb  ;  and  3.  That  the  venous  blood  returning  from  an  inflamed  limb 
is  warmer  than  the  corresponding  current  on  the  opposite  side  of  the 
bod3^”  It  is  probable  that  there  is  always  some  local  increase  of  heat  in 
inflammation;  although  the  observations  of  Billroth,  0.  Weber,  and 
others,  would  appear  to  denote  that  the  oceurrence  is  not  constant.  The 
rise  of  temperature  is  probably  but  moderate;  to  the  patient,  however,* 
it  appears  greater  than  it  is  in  reality — as  Travers  truly  remarks,  ‘‘  the 
nerves  measure  the  sensation  and  not  the  degree  of  heat.”  In  many 
cases  the  sensation  of  the  patient  is  that  of  burning  in  the  part,  although 
the  actual  rise  in  temperature  may  be  but  trifling.  This  is  owing  to  the 
exalted  sensibility  of  the  nerves. 

How  far  the  increased  temperature  is  dependent  on  the  mere  hypersemia 
or  on  the  changes  going  on  between  the  blood  and  tissues  of  the  part,  is 
not  j'et  decided.  It  must  be  remembered,  however,  that  in  all  processes 
in  the  body  in  which  determination  of  blood  takes,  as  in  blushing  or 
parturition,  the  temperature  rises.  This  can  clearly  not  be  owing  to 
an}-"  production  of  heat  during  respiration,  which  may  account  for  the 
general  heat  of  the  blood,  but  not  for  its  local  increase. 

5.  Modification  of  Function^  Use,  or  Nutrition,  invariably  occurs  in 
inflammation,  and  furnishes  important  local  symptoms.  The  Functional 
Activity  of  an  organ  is  increased,  in  the  earlier  stages  at  least  of  inflam¬ 
mation  ;  and  the  character  of  the  secretions  from  the  part  is  materially 
modified.  Thus,  when  the  mucous  membrane  of  the  urethra  is  inflamed, 
there  is  copious  discharge  from  it ;  and  this  is  not  mucous,  but  purulent. 

The  Use  of  the  part  aft'ected  is  greatly  interfered  with;  thus  the  bladder 
can  contain  no  urine,  the  eye  cannot  bear  the  light,  nor  can  a  joint  be 
moved,  when  inflamed. 

The  Nutrition  of  the  inflamed  tissues  is  modified  or  arrested ;  hence, 
wasting,  softening,  or  contraction,  are  common  accompaniments  of 
inflammation. 

Constitutional  Symptoms. — The  severity  of  the  constitutional 
symptoms  will  depend  on  the  intensity  and  the  extent  of  the  inflamma¬ 
tion  ;  on  the  vital  importance  of  the  part  affected  by  it ;  on  the  amount 
of  local  irritation ;  and  on  the  origin  of  the  inflammation  from  external 


102 


INFLAMMATION. 


or  from  internal  causes.  Thus,  a  moderate  degree  of  inflammation  in  a 
part  of  no  vital  importance,  as  the  skin,  and  occasioned  by  an  external 
cause,  as  an  abrasion,  gives  rise  to  no  appreciable  constitutional  disturb¬ 
ance.  But  if  the  inflammation  be  wide-spread,  as  that  of  diffused  ery¬ 
sipelas  ;  or  if  it  arise  from  constitutional  causes ;  or  if  there  be  much 
local  tension,  as  in  whitlow ;  or  if  the  part  affected  be  of  great  import¬ 
ance,  as  the  larynx  or  the  eye,  then  the  general  symptoms  become  pro¬ 
portionally  severe. 

The  constitutional  disturbance  in  inflammation  always  assumes  the 
form  of  fever  —  Inflammatory  or  Symptomatic  Fever^  or  Pyrexia. 
Although  the  blood  ma}^  previously  have  been  in  a  diseased  state, 
and  so  have  predisposed  the  patient  to  the  occurrence  of  an  inflam¬ 
mation,  the  inflammatory  fever  is  invariably  secondaiy,  being  consecu¬ 
tive  to  the  local  affection.  It  is  the  true  surgical  fever,  no  febrile  dis¬ 
turbance  occurring  in  surgical  practice  except  as  a  consequence  of,  and 
secondary  to,  local  disease  or  injury.  This  fever  appears  to  result  pri¬ 
marily  from  deterioration  of  the  blood,  occasioned  by  the  products  of 
the  rapid  waste  of  the  tissues  that  are  the  seat  of  the  local  disease — the 
inflammation — being  poured  into  it  more  quickly  than  they  can  be  elimi¬ 
nated  by  the  different  emunctories  of  the  system,  and  thus  accumulatiug 
in  the  blood.  The  presence,  in  excessive  quantity,  of  this  effete  matter 
in  the  deteriorated  blood,  occasions  congestion  and  disturbance  of  func¬ 
tion  of  the  excretory  organs,  and  is  liable  to  give  rise  in  various  viscera 
to  consecutive  inflammations,  sometimes  of  a  low"  type. 

Inflammatory  fever,  or  pyrexia,  presents  an  infinite  variety  of  forms  ; 
the  type  which  it  assumes  being  finally  dependent,  1st,  on  the  state  of 
the  blood ;  2d,  on  the  condition  of  the  nervous  system ;  and,  3d,  on 
the  occurrence  of  certain  local  or  specific  symptoms  dependent  on  the 
seat  of  the  inflammation.  These  varieties  in  the  type  of  the  fever 
arrange  themselves  practically  into  three  classes:  1.  Sthenic,  or  typical 
inflammatory  fever;  2.  Asthenic,  or  typhoid  fever;  3.  Irritative,  or  ner¬ 
vous  fever.  In  all  these  forms  of  fever  there  are  three  distinct  stages : 
those  of  invasion,  exacerbation,  and  decline.  In  practice,  the  recogni¬ 
tion  of  the  type  or  form  that  the  constitutional  fever  of  inflammation 
assumes  is  of  the  first  consequence.  The  treatment  of  the  patient,  irre¬ 
spective  of  the  topical  means  that  the  special  local  affection  may  require, 
being  altogether  determined  by  the  particular  form  that  the  concomitant 
constitutional  disturbance  assumes,  it  cannot  be  too  sedulously  borne 
in  mind  that  the  local  signs,  “  the  redness,  swelling,  heat,  and  pain,”  do 
not  in  themselves  comprise  all  the  morbid  phenomena  of  an  inflamma¬ 
tion  ;  there  is  always  concomitant  constitutional  disturbance,  sometimes 
preceding  or  predisposing  to  the  development  of  the  local  signs,  in  all 
cases  modifjdng  their  characters,  and  invariably,  wdiether  preexisting 
or  not,  increased  by  the  excitation  of  the  local  disease.  It  is  the  char¬ 
acter  of  this  constitutional  disturbance  or  fever  that  will  at  last  deter¬ 
mine  the  kind  of  treatment  to  be  adopted  ;  and  it  consequently  requires 
to  be  closely  studied. 

1.  The  Sthenic  form  of  inflammatory  fever,  true  pyrexia,  occurs  in 
individuals  of  healthy  constitution,  young  or  middle-aged,  in  connection 
with  those  forms  of  inflammation  that  are  of  an  active,  acute  character, 
and  not  unfrequently  consequent  upon  injury. 

In  this  form  of  fever  the  stage  of  invasion  is  very  slightly  marked, 
tliough  it  alw-ays  occurs.  There  are  rigors,  with  some  slight  depression 
of  the  nervous  system ;  but  these  S3unptoms  may  be  so  transient  as  to 
escape  observation  entirel^q  and  speedily  terminate  in  the  stage  of  febrile 


ASTHENIC  INFLAMMATORY  FEVER. 


103 


reaction.  In  the  majorit}^  of  cases,  it  is  not  until  the  constitutional  dis¬ 
turbance  has  reached  this  stage  that  it  attracts  attention.  The  skin  is 
now  hot  and  usually  dry,  and  there  is  a  rise  in  the  general  temperature 
of  the  body  as  measured  by  the  thermometer.  The  pulse  is  full,  bound¬ 
ing,  or  thrilling,  and  quickened  b}"  thirty'  or  forty  beats  in  the  minute 
above  its  normal  rate.  If  the  tissue  or  organ  atfected  be  the  mucous 
membrane,  skin,  or  a  glandular  structure,  as  the  testis  or  mamma,  the 
pulse  is  compressible,  though  full ;  if  a  serous  membrane  be  inflamed,  it 
is  small,  incompressible,  and  wiry ;  if  a  flbrous  tissue  be  the  seat  of  dis¬ 
ease,  it  is  hard  and  full.  The  secretions  are  arrested  or  diminished  in 
quantity  ;  hence  the  urine  is  high  colored  and  acid,  the  bowels  are  con¬ 
fined,  the  tongue  coated  with  a  white  fur,  and  the  mouth  clamm}", 
usually  with  much  thirst.  There  is  a  feeling  of  great  languor,  and  the 
head  is  often  heav}^  and  hot. 

As  the  fever  declines,  if  a  favorable  termination  occur,  the  system  not 
uncommonly  relieves  itself  by  a  critical  evacuation :  from  the  skin,  by 
abundant  acid  perspiration ;  from  the  kidneys,  by  the  free  deposition  of 
lithates  in  the  urine;  from  the  bowels,  b}’  diarrhoea;  and  from  some  of 
the  mucous  surfaces,  by  hemorrhage.  The  tongue  cleans,  the  pulse  sub¬ 
sides  in  frequencj^  and  strength,  the  secretions  become  freer,  the  thirst 
lessens,  and  strength  and  appetite  return.  Should  the  fever  not  take  a 
favorable  course,  death  maj^  ensue  by  the  occurrence  of  serious  visceral 
complications ;  the  lungs  and  brain  being  especially  apt  to  suffer, 
becoming  the  seats  of  fatal  inflammatory  mischief ;  or  the  sthenic  form 
of  the  disease  may  gradually  merge  into  those  tj^pes  that  are  character¬ 
ized  by  debility  and  irritation. 

2.  The  Asthenic  form  of  inflammatoiy  fever  principally  occurs  in 
those  individuals  whose  constitutions  are  broken  by  privation,  dissipa¬ 
tion,  or  by  any  of  the  general  depressing  causes  of  disease,  as  grief, 
anxiety,  or  long  residence  in  a  vitiated  atmosphere.  In  constitutions 
such  as  these,  frequently  met  with  in  all  classes,  but  especiall}^  amongst 
the  poorer  residents  in  large  towns,  inflammatory  fever  almost  invariably 
assumes  a  low  type.  There  is  also,  in  this  variety  of  the  disease,  a 
special  tendency  to  complication  with  visceral  mischief ;  the  lungs  being 
peculiarly  apt  to  become  aflected  by  a  low  or  congestive  form  of  pneu¬ 
monia. 

The  asthenic  form  of  the  disease  may  come  on  as  a  sequence  of  the 
sthenic  variety ;  the  symptoms  gradually  merging  into  those  of  a  low 
form,  and  being  characterized  by  debility  rather  than  by  strength  of 
action;  the  pulse  becoming  weaker  though  its  frequency  is  kept  up,  the 
tongue  becoming  brown  and  diy,  with  a  tendency  to  the  early  superven¬ 
tion  of  delirium  of  a  mutterinor  kind. 

_  o 

When  the  fever  assumes  the  asthenic  form  from  the  very  first,  the 
period  of  depression  is  strougty  marked,  and  often  prolonged  for  many 
hours,  reaction  coming  on  gradualty  and  imperfectly,  alternating  with 
the  depression  against  which  the  system  is  struggling.  Even  when  fully 
established,  the  s3^mptoms  of  the  stage  of  reaction  are  uot  veiy  active : 
there  is  throughout  an  appearance  of  heaviness  or  stupor  about  the 
patient,  with  little  activity  of  the  intellectual  faculties,  and  an  earty  ten- 
denc}^  to  delirium  of  a  low  form,  especialty  at  night ;  the  pulse  is  feeble, 
though  quick :  the  skin  is  either  moderatety  hot,  or  else  pungent  and 
burning;  the  tongue  brown  and  diy,  with  sordes  rapidlv  accumulating 
about  the  lips  and  teeth  ;  the  cheeks  are  often  flushed,  and  the  e3’es 
bright  and  staring.  As  the  third  stage  comes  on,  if  the  patient  recover, 
critical  evacuations  of  a  hemorrhagic  or  diarrhoeal  character  appear ; 


104 


INFLAMMATION. 


the  pulse  subsides,  the  tongue  gradually  and  slowly  cleans  from  the 
sides  and  tip,  and  the  patient  slowly  and  imperfectly  regains  his 
strength ;  the  convalescence  being  often  interrupted  by  interciirrent 
disease,  and  the  powers  of  the  constitution  being  frequently  broken  for 
montlis,  or  for  life.  If  the  disease  take  an  unfavorable  course,  the 
weakness  of  pulse  and  dark  incrustation  of  tongue  increase ;  the  skin 
becomes  cold;  hiccup,  subsultus,  dyspnoea,  or  coma  supervene;  and 
death  occurs  from  exhaustion,  or  as  the  result  of  visceral  complication. 

3.  The  Irritative  fever  is  of  a  less  specific  type.  It  is  usually  associated 
with  the  asthenic  form,  the  nervous  system  being  especially  implicated. 
It  occurs  to  individuals  whose  mental  powers  have  been  overwrought,  or 
whose  nervous  systems  have  been  irritated  and  shattered  by  intem¬ 
perance.  It  is  characterized  by  irregularity  in  its  actions,  by  sudden 
exacerbations,  and  by  a  rapid  decline.  The  several  febrile  symptoms 
run  high  in  the  earl}'  stages.  The  pulse  soon  becomes  sharp  and  small ; 
there  are  high  delirium  of  a  furious  kind,  wildness  of  eye,  and  heat  of 
head.  But  these  symptoms  soon  give  way  to  signs  of  debility  and  ex¬ 
haustion,  and  death  takes  place  from  coma  and  cerebral  irritation. 

Terminations  of  Acute  Inflammation. — There  are  two  ways  in 
which  infiammation  may  terminate  without  leaving  any  traces  of  its 
presence  in  the  part  affected :  these  are  by — 1.  Resolution^  and  2. 
Metastasis. 

1.  The  termination  by  Resolution  simply  means  a  return  to  health. 
The  pain  and  heat  first  subside,  the  swelling  lessens,  and  lastly  the  red¬ 
ness  passes  away:  the  constitutional  symptoms  also  disappear.  With 
regard  to  the  more  intimate  changes  in  the  part  itself,  it  will  be  seen 
that  the  dilated  vessels  contract,  and  the  stagnant  masses  of  blood-disks 
are  pushed  on  and  broken  up  by  streams  finding  their  way  into  and 
against  them.  Absorption,  which  had  been  held  in  check  during  the 
continuance  of  inflammation,  comes  into  play  and  removes  the  extrava- 
sated  matters ;  and  secretion  becomes  more  active,  and  helps  to  unload 
the  part.  Resolution  may  in  this  way  be  complete  ;  or  it  may  go  on  to 
a  certain  point  and  then  stop,  leaving  one  or  other  of  the  effects  that  will 
immediately  be  mentioned. 

2.  By  Metastasis  is  meant  a  change  in  the  seat  of  the  inflammation — 
its  sudden  and  complete  disappearance  from  one  part  and  reappearance 
in  another.  This  is  of  extremely  rare  occurrence ;  it  is  occasionally  seen, 
however,  as  in  the  inflammation  of  the  testis  that  suddenly  supervenes 
on  the  disappearance  of  a  gonorrhoeal  discharge. 

Besides  these  true  terminations,  inflammation  commonly  passes  from 
the  ordinary  and  primary  condition  into  some  other  form  of  the  disease. 
Thus,  for  instance,  the  acute  disease  may  merge  into  the  chronic  form  ; 
if  plastic  matter  or  lymph  be  thrown  out,  adhesive  inflammation  is  said  to 
have  occurred;  when  pus  is  produced,  we  have  suppurative  inflammation ; 
when  an  ulcer  forms,  ulcerative  inflammation  is  said  to  have  set  in ;  and 
when  the  inflammatory  action  is  of  such  intensity  as  to  cause  the  death 
of  the  part  affected,  gangrenous  infiammation  has  occurred.  These  dif¬ 
ferent  conditions  vary  so  widely  from  each  other,  as  to  require  separate 
and  distinct  consideration. 

Extension. — When  inflammation  has  once  been  set  up  in  a  part,  it 
may  extend  to  other  portions  of  the  system  in  four  distinct  wa3^s. 

1.  Local  extension  may  occur  by  the  inflammation  spreading  along  the 
tisue  affected  in  its  continuity ;  as,  for  instance,  along  the  skin,  areolar 
tissue,  or  mucous  membrane. 

2.  Inflammation  may  also  spread  by  contiguity  of  tissue,  passing  from 


EFFECTS  OF  INFLAMMATION. 


105 


one  affected  structure  to  an  adjacent  healthy  one;  thus  we  see  the  oppo¬ 
site  surfaces  of  an  inflamed  joint  involved  in  disease  at  opposed  points. 
In  such  cases,  the  part  first  inflamed  probably  acts  as  an  irritant  to  that 
with  which  it  comes  into  contact,  in  this  w'ay  inducing  inflammation  in 
the  latter. 

3.  Inflammation  may  extend  to  distant  parts  through  the  medium  of 
the  blood ;  this  fluid  being  altered  and  depraved,  and  increasing  the 
liability  to  inflammation  in  other  parts,  as  in  some  of  the  erratic  forms 
of  erysipelas  ;  or  conveying  pus  to  a  distance,  as  in  phlebitis,  and  thus 
giving  rise  to  numerus  centres  of  inflammation. 

4.  Inflammation  may  appear  in  a  distant  part  in  consequence  of 
metastasis,  as  has  been  already  stated. 

Effects  of  Inflammation. — In  speaking  of  the  local  symptoms  of 
inflammation,  reference  was  made  to  the  occurrence  of  effusions  of 
various  kinds,  and  of  modifications  in  the  secretions  of  the  part  affected. 
These  effects  must  now  be  examined  in  greater  detail. 

Effusions  are  not  invariably  due  to  inflammation.  Venous  congestion 
will  produce  an  excessive  transudation  of  fluid  of  a  more  or  less  watery 
character,  constituting  oedema  in  the  areolar  tissue,  and  cZropsy  in  serous 
or  synovial  cavities.  Thus,  if  the  veins  of  the  leg  be  compressed,  oedema 
of  the  foot  will  result :  if  those  of  the  liver  be  obstructed,  ascites  will 
follow.  Congestion  of  the  renal  veins  produces  albuminuria.  If  the 
pressure  on  the  vessels  be  great,  the  capillaries  may  be  distended  till 
they  rupture,  giving  rise  to  effusion  of  blood,  as  in  some  forms  of  epis- 
taxis  and  haematuria. 

The  proper  effusions  of  inflammation  are — 1.  Blood  ;  2.  Liquor  San¬ 
guinis  ;  3.  Serum.  These  effusions  are  in  a  great  measure  mechanical, 
depending  on  the  dynamic  state  of  the  vessels,  though  doubtless  in  many 
instances  modified  by  other  causes  of  a  vital  character.  Fibrine,  or 
tymph,  though  usually  spoken  of  as  an  inflammatoiy  effusion,  differs 
remarkably  in  its  vital  characters  from  the  rest,  and  will  be  considered 
elsewhere. 

The  frequency  with  wdiich  one  or  other  form  of  effusion  occurs  in 
different  tissues,  or  organs,  varies  greatly.  Paget  observes,  “each  tissue 
has  its  proper  mode  and  products  of  inflammation ;  hence  particular 
kinds  of  effusions  are  very  rare  in  some,  although  of  common  occurrence 
in  other  parts. 

1.  Effusion  of  Blood  often  occurs  in  small  quantity,  tinging  the  other 
products  of  inflammation.  When  this  is  the  case,  the  coloring  matter  is 
broken  down  and  dissolved,  a  condition  indicative  of  a  low  state  of  the 
constitutional  powers.  In  other  cases,  the  hemorrhage  ma}^  be  abundant, 
the  character  of  the  blood  beins:  but  little  changed.  This  effusion  is 
dependent  upon  overdistension  of  the  vessels,  with  softening  of  the 
tissues,  giving  rise  to  rupture  of  the  capillaries.  Hemorrhage  of  this 
kind  most  frequently  occurs  from  mucous  surfaces,  which  readil}^  bleed 
when  inflamed.  It  maj''  also  happen  from  the  rupture  of  new  vessels  in 
freshly  deposited  l3^mpli  ;  or  it  ma}^  arise  from  migration  of  the  red  cor¬ 
puscles  through  the  walls  of  the  capillaries. 

2.  Effusion  of  Liquor  Sanguinis. — In  this  case,  the  fluid  parts  of  the 
blood  transude,  leaving  the  corpuscles  behind.  It  is  occasionally  met 
with  in  so-called  serous  effusions,  into  the  tunica  vaginalis  for  instance; 
so  also  the  serum  contained  in  the  bleb  of  a  blister  is  really  liquor  san¬ 
guinis  ;  and  Paget  has  found  that  in  this  there  is  most  fibrine  when  there 
is  most  strength  of  constitution.  This  fluid  is  not  uncommonl3^  met 
with  in  the  subcutaneous  and  submucous  areolar  tissues ;  about  the 


106 


INFLAMMATION. 


glottis,  and  in  the  scrotum,  for  instance,  giving  rise  to  a  gelatinous  semi¬ 
transparent  swelling  of  the  part.  In  these  cases,  the  more  fluid  portions 
are  sometimes  absorbed,  leaving  the  fibrine,  thus  constituting  the  con¬ 
dition  termed  solid  oedema.  The  flbrine  in  this  eff’usion  often  does  not 
coagulate  so  long  as  it  is  retained  in  the  body ;  but  when  it  is  removed, 
solidification  ensues. 

3.  Sei'ous  or  Albuminous  Effusions  are  very  common  in  slight  or  sub¬ 
acute  inflammations  of  serous  and  areolar  tissues,  giving  rise  to  dropsies 
and  oedema.  They  most  frequentl}^  contain  a  small  admixture  of  fibrine, 
approaching  somewhat  to  the  characters  of  the  last-mentioned  effusion. 
The  quantity  of  the  fibrin  contained  in  them  is  usually  a  nieasure  of  the 
desiree  of  the  inflammation.  These  serous  accumulations  form  and  are 
absorbed  with  great  rapidity,  and  their  absorption  is  usually  most  rapid 
when  the  fibrillation  is  least. 

Closely  connected  with  these  effusions  are  changes  in  the  consistence 
of  the  part  afiected  :  these,  however,  being  in  part  the  results  of  the  local 
disturbance  of  nutrition,  which  is  one  of  the  factors  of  the  inflammatory 
process.  These  changes  ma}’  be  of  two  kinds :  Induration.^  chiefly  as  a 
consequence  of  chronic  inflammation,  occasioned  by  the  turgescent  state 
of  the  vessels  of  the  part,  or  the  efifusion  of  plastic  matter  within  it ;  and 
Softening.,  chiefl}"  after  acute  inflammation,  depending  partly  on  the  infil¬ 
tration  of  effused  liquids  into  the  textures,  and  partly  on  a  disintegration 
of  the  substance,  and  thus  a  lessening  of  the  consistence  even  of  the 
hardest  tissues,  by  impairment  of  their  nutrition  :  thus  an  inflamed  bone 
ma}^  be  cut  and  pared  down  with  a  knife,  or  the  ligaments  of  an  inflamed 
joint  become  so  soft  as  to  admit  of  spontaneous  dislocation.  This  soft¬ 
ening  may  ultimatel}'  lead  to  the  interstitial  absorption  of  a  part,  which 
becomes  shrunken  and  contracted  after  inflammation.  Ulceration.,  as 
will  hereafter  be  fully  stated,  is  not  an  unfrequent  consequence  of  this 
softening  and  atroph}",  as  we  see  in  those  joints  that  have  undergone 
inflammation. 

Interstitial  absorption  and  gradual  luasting  of  a  part,  without  previous 
softening,  often  occur  as  an  effect  of  inflammation.  Thus,  a  blow  on  the 
hip  maj"  occasion  absorption  and  shortening  of  the  neck  of  the  femur. 

Loss  of  transparency  in  structures  that  are  normally  translucent  is  a 
common  effect  of  inflammation,  as  ma}’  every  da}^  be  observed  in  the 
cornea  or  in  the  capsule  of  the  ciystalline  lens.  In  some  cases  this 
rather  depends  upon  a  modification  of  nutrition  than  upon  the  deposit 
of  new  matter  upon  the  part ;  in  other  cases,  again,  it  proceeds  from  the 
deposition  of  fibrinous  matter. 

Secretions  of  Tissues  and  Organs  undergo  changes  in  quantit}^  and 
qualit}^,  under  the  influence  of  inflammation.  The  quantit}^  is  at  first 
increased ;  but  during  the  active  stage  of  the  inflammation,  when 
there  is  much  tension,  it  becomes  diminished,  the  part  being  almost  dry; 
as  the  inflammatoiy  action  subsides,  and  relaxation  of  the  vessels  ensues, 
it  again  becomes  increased. 

The  alteration  in  qualit}"  in  secretions  from  glands  is  chiefly  due  to 
the  admixture  of  morbid  secretions  from  the  mucous  membrane.  When 
a  serous  membrane  is  inflamed,  the  secretion  not  onlv  accumulates  in 
greatly  increased  quantit}',  as  in  acute  h3'drocele,  but  it  becomes  turbid 
b\"  the  admixture  of  flakes  of  13’mph,  which  are  sometimes  so  abundant 
as  to  give  it  a  puriform  appearance.  In  other  cases  true  pus  is  formed, 
as  in  inflammation  of  the  anterior  chamber  of  the  e3"e,  terminating  in 
hypop3'on.  In  inflammation  of  the  areolar  tissue  the  quantit3^  of  fluid 
is  either  simply  increased,  or  it  becomes  fibrinous,  occasioning  solid 


VARIETIES  AND  CAUSES  OF  INFLAMMATION.  107 


oedema  and  induration.  In  inflammation  of  the  mucous  membranes 
the  most  important  modifications  of  secretion  occur.  The  first  eflfect  is 
to  cause  the  transudation  of  a  serous  fluid  from  the  mucous  membrane, 
the  secretion  becoming  clear,  watery,  and  abundant.  As  the  inflamma¬ 
tion  increases,  exudation-corpuscles  and  large  quantities  of  epithelial 
scales  are  thrown  off,  and,  mixing  with  the  mucus,  make  it  viscid  and 
tenacious — ropy,  as  it  is  termed.  In  the  more  advanced  stages  we  find 
jDus  and  exudation-corpuscles  with  epithelial  scales,  constituting  the 
various  forms  of  muco-pus  and  of  true  purulent  secretion. 

Varieties  of  Inflammation. — The  symptoms,  terminations,  and 
effects  of  inflammation  that  have  just  been  described,  are  those  which 
characterize  the  more  acute  or  ordiuaiy  forms  of  the  disease.  In  practice, 
however,  w’e  recognize  many  important  varieties.  These  may  be  referred 
to  three  heads,  as  they  affect  its  Duration^  its  Intensity^  or  its  Character. 

1.  Duration, — The  disease  may  be  acute  or  chronic,  varying  from  a 
few  days  to  many  3"ears,  being  especially  persistent  in  those  structures 
that  are  naturally  least  vascular,  as,  for  instance,  bones  and  joints. 
Chronic  inflammation  will  be  described  in  a  subsequent  part  of  this 
chapter. 

2.  Intensity. — When  the  sj^mptoms  are  well  marked,  the  redness  and 
heat  great,  the  tension  considerable,  and  perhaps  the  pain  severe,  with 
corresponding  constitutional  disturbance,  the  inflammation  is  said  to  be 
active  or  acute  ;  when  of  a  less  intense  character,  it  is  termed  subacute  ; 
and  when  there  are  merely"  redness  and  swelling,  with  little  or  no  pain, 
and  but  slight  constitutional  disturbance,  the  disease  is  said  to  be  of  a 
passive  kind.  The  intensit}^  of  the  inflammation  is  commonl}'  greater 
in  proportion  to  the  short  duration  of  the  disease,  and  less  in  the  more 
chronic  cases ;  but  veiy  frequently'  inflammation  of  short  duration  may' 
be  subacute  or  passive,  whereas  some  very  chronic  forms  may  retain 
great  activity,  and  are  especially'  liable  to  recurrent  active  attacks. 

3.  Character. — If  the  inflammation  be  circumscribed,  occurring  in  a 
healthy  constitution,  and  tending  after  a  moderate  time  to  terminate  in 
resolution,  it  is  called  healthy  or  phlegmonous.  If  the  vessel  become 
distended  and  dilated,  the  blood  circulate  slowly,  the  redness  be  of  a 
purplish  tinge,  and  the  swelling  considerable,  with  but  little  heat,  the 
disease  is  said  to  be  congestive.  Of  unhealthy  inflammation  there  are 
numerous  varieties:  the  diffuse.,  having  a  tendency'  to  spread  widely'  un¬ 
checked;  the  strumous.,  modified  by'  scrofula;  and  the  specific  inflam¬ 
mations  that  arise  from  special  causes,  and  are  frequently  capable  of 
self-propagation. 

Causes  of  Inflammation. — The  causes  of  inflammation  may'  be 
divided,  like  those  of  all  other  diseases,  into  predisposing  and  exciting  ; 
and  these  again  may^  either  be  strictly'  local,  or  may'  act  locally'  through 
the  medium  of  the  constitution. 

Local  Predisposing  Causes. — Though  every'  tissue  of  the  body'  is  sus¬ 
ceptible  to  inflammation,  y'et  some  parts  are  more  liable  to  it  than  others. 
This  cannot  be  owing  to  any'  greater  degree  of  vascularity' ;  for  we  find 
that  the  tissues  lining  the  interior  of  a  joint  more  readily'  and  more  vio¬ 
lently'  inflame,  though  they'  are  almost  extravascular,  than  a  portion  of 
the  mucous  membrane,  which  is  abundantly  supplied  with  vessels. 
Indeed,  serous  and  synovial  membranes  are  more  liable  than  most  other 
tissues  to  inflammatory  excitement.  Whatever  the  reason  of  this  may' 
be,  there  are  two  sets  of  causes  that  more  especially'  predispose  tissues 
to  inflammation. 


108 


INFLAMMATION. 


Thus,  habitual  overuse  or  overstimulation  of  a  part,  by  producing 
determination  of  blood  to  it,  may  readily  drive  it  into  inflammation. 

When  a  part,  having  once  been  the  seat  of  inflammation,  has  been  left 
in  a  weakened  or  impaired  state,  it  will  be  more  liable  to  the  occurrence 
of  a  second  attack  of  inflammation,  having  less  resisting  powder ;  hence, 
also,  subsequent  attacks  are  induced  by  less  active  exciting  causes  than 
were  required  at  first  to  call  the  disease  into  action ;  we  see  this  in  the 
inflammatory  affections  of  e3’es  and  joints.  Then,  again,  a  tendency"  to 
local  congestion  or  statis  will  dispose  to  inflammation,  veiy  slight  over- 
stimulation  inducing  the  disease  when  the  vessels  of  the  part  are  already 
overloaded  ;  this  is  often  seen  in  the  case  of  varicose  veins,  the  congestion 
of  the  skin  readily  running  into  inflammation. 

Constitutional  Predisposing  Causes. — It  is  of  great  consequence  to 
ascertain  whether  ai\y  constitutional  predisposition  to  inflammation  exists ; 
and  if  so,  what  its  precise  nature  is  ;  for  the  progress  of  the  local  affec¬ 
tion  will  in  a  great  measure  be  dependent  on  the  amount  of  constitutional 
predisposition.  The  constitutional  predisposing  causes  are  of  two  kinds. 

1.  Inflammation  is  predisposed  to  by  a  state  of  general  overstimula¬ 
tion  of  the  vascular  and  nervous  systems.  This  condition  ma^y  be 
hereditaiy,  as  in  the  sanguine  temperament,  or  dependent  on  3^outh  or 
sex ;  or  it  may  be  acquired  b3’’  habitual  indulgence  at  table,  the  induc¬ 
tion  of  plethora  and  gout  giving  rise  to  a  habit  of  body  that  is  pecu¬ 
liarly  favorable  to  the  development  of  inflammation.  Inflammations 
occurring  in  this  habit  of  body  are  usually  sthenic,  though  not  unfre- 
quently  accompanied,  in  the  case  of  persons  accustomed  to  alcoholic 
stimulants,  by  irritative  fever. 

2. ^  A  directly  opposite  condition  of  the  S3"stem  equally  disposes  the 
person  to  inflammatory  attacks.  Thus,  a  state  of  vascular  and  nervous 
depression.,  by  lessening  the  reacting  power  of  the  constitution,  causing 
a  loss  of  tone  in  the  vascular  S3"stem,  with  ready  tendenc3^  to  congestion 
of  the  vessels  and  to  stagnation  of  blood,  disposes  to  inflammation. 
In  this  wa3’  inflammatoiy  actions  are  especially  apt  to  occur  in  scrofu¬ 
lous  patients,  in  whom  the  general  powers  are  enfeebled  ;  and  in  such 
individuals  the3^  occur  under  the  influence  of  exciting  causes  less  in 
degree  than  those  which  affect  persons  in  whom  nutrition  is  more  actively 
carried  on.  Here  inflammation  usually  assumes  the  passive,  congestive, 
or  asthenic  forms. 

Exciting  Causes. — These  are  very  numerous  and  simple  in  their  action. 
Commonl3q  mechanical  injuries  are  those  that  occasion  surgical  inflam¬ 
mations;  which  are,  indeed,  set  up  by  nature  as  the  means  of  repairing 
the  effects  of  the  injuiy. 

Chemical  agencies.,  as  the  application  of  caustics  and  undue  extremes 
of  heat  and  cold,  are  also  amongst  the  most  common  exciting  causes. 
The  application  of  the  virus  of  certain  morbid  poisons.,  as  of  S3q3hilis 
and  the  malignant  pustule,  directly  occasions  it.  And  lastl3q  certain 
states  of  the  blood  give  rise  to  it,  as  we  observe  in  those  conditions  of 
the  S3"stem  in  which  boils,  carbuncles,  etc.,  are  produced. 

Inflammation  will  often,  though  not  necessaril3q  vaiy  greatly  in  char¬ 
acter  accordino;  as  it  arises  from  a  constitutional  or  a  traumatic  cause. 

_  O 

When  an  inflammation  of  an  organ,  as  of  the  lung,  arises  from  an  idio¬ 
pathic  or  constitutional  cause,  a  predisposition  must  previously  have 
existed  in  the  system,  leading,  under  the  influence  of  slight  variations 
of  external  circumstances,  as  exposure  to  a  draught  of  cold  air  or  to 
wet,  to  the  development  of  the  local  disease.  The  inflammation  wdll, 
therefore,  usually  be  prone  to  become  wide-spread,  and  frequently  has  a 


TKEATMENT  OF  INFLAMMATION. 


109 


tendency  to  assume  a  low  tjqoe.  In  the  case  of  a  similar  inflammation, 
as  of  the  lung,  following  an  injury,  as  a  wound  of  the  organ,  in  an 
otherwise  perfectly  healthy  subject,  the  disease  will  be  localized  in  the 
seat  of  injury;  having  little  tendency  to  spread,  and  usually  affecting 
the  active  sthenic  character.  If,  however,  the  constitution  be  in  a  bad 
state,  and  the  blood  unhealthy,  or  if  the  patient  be  exposed  to  unfavor¬ 
able  hj’gienic  conditions,  a  very  slight  injury  may  develop  a  wide-spread 
inflammation,  which  will  then  always  assume  a  low  and  usually  an  ery¬ 
sipelatous  form. 

Treatment  of  Inflammation. —  It  is  interesting,  and  possibly 
practicall}"  useful,  to  study  the  inflammatory  process  pathologically  and 
ph^'siologically,  and  to  recognize  in  it  a  modification  or  aberration  of 
nutrition  rather  than  a  distinct  disease.  Yet,  when  we  have  to  deal 
with  it  therapeutically  or  surgicallj^,  when  we  meet  with  it  in  the  hos¬ 
pital-ward  and  not  in  the  dead-house,  or  in  the  web  of  the  frog’s  foot  in 
the  physiological  laboratoiy,  we  must  be  prepared  to  encounter  it  as  a 
disease  often  of  the  most  fatal  and  destructive  character ;  always  dan¬ 
gerous  to  life  or  to  organ  when  it  passes  certain  limits ;  often  dangerous 
to  integrit}^  of  structure,  even  in  its  simplest  forms  ;  and,  when  affecting 
certain  constitutions,  as  the  strumous,  liable  to  become  most  difficult 
of  cure  and  inveterately  chronic.  Hence  I  shall  speak  of  inflammation 
as  we  meet  with  it  in  surgical  practice  as  essentially  and  substantially 
a  disease^  to  be  treated,  cured,  or  removed  as  such. 

The  Treatment  of  Inflammation  may  be  divided  into  the  Preventive 
and  the  Curative. 

The  Preventive  Treatment  can  be  employed  only  in  inflammation 
supervening  on  injuiy.  In  it  the  principal  point  to  be  attended  to  is, 
the  removal  of  the  local  and  constitutional  causes  of  irritation.  By 
doing  this,  the  occurrence  of  inflammation  in  a  part  that  has  been 
injured  or  otherwise  disposed  to  its  accession  ma}^  be  entirely  prevented, 
or,  if  this  be  not  accomplished,  much  lessened  in  severity. 

The  local  preventive  treatment  of  inflammation  is  best  carried  out  by 
the  removal  of  all  sources  of  irritation,  by  absolute  rest  of  the  part,  and 
by  the  free  application  of  cold.  If  the  injury  be  superficial,  and  not 
very  severe,  lint  dij^ped  in  cold  water,  frequently  renewed,  may  be 
applied  ;  or,  if  the 
skin  be  unbroken, 
an  evaporating  lo¬ 
tion  may  be  used. 

Should  a  limb  or 
joint  be  severely 
injured,  cold  irri¬ 
gation  will  be  a 
preferable  mode  of 
reducing  its  tem- 
l)erature.  This  may 
most  conveniently 
be  done  by  sus¬ 
pending  over  the 
part  a  large  wide¬ 
mouthed  bottle  full 
of  water,  in  which 
a  few  pieces  of  ice 
may,  if  necessary, 
be  put;  one  end  of  a  skein  of  cotton,  well  wetted,  is  then  allowed 


Fig.  57. 


Inigatiug  Apparatus. 


110 


INFLAMMATION. 


to  hang  in  the  water,  wliilst  the  other  is  brought  over  the  side  of  the 
bottle.  This,  acting  as  a  syphon,  causes  a  continual  dropping  upon  the 
part  to  which  the  cold  is  to  be  applied  (Fig.  57).  In  some  cases  the 
application  of  pounded  ice  in  a  bladder,  or  of  cold  evaporating  lotions, 
ma}^  be  preferred  to  the  irrigation.  Dry  cold  may  be  advantageously 
substituted  for  the  moist  in  many  cases.  It  has  the  advantage  of  not 
soddening  the  skin,  and  is  less  likely  to  be  followed  b3'^  gangrene,  which 
ma^"  result  in  consequence  of  the  too  incautious  or  long-continued  use 
of  cold  and  moisture.  The  dry  cold  is  best  applied  by  putting  pounded 
ice  into  a  thin  vulcanized  India-rubber  bag,  as  recommended  by 
Esmarch. 

At  the  same  time  all  constitutional  irritation  must  be  removed  by 
abstinence,  rest,  and  a  free  aperient. 

In  undertaking  the  Curative  Treatment  of  inflammation,  the  Surgeon 
must  not  allow  himself  to  be  guided  by  the  name  of  the  affection  with 
w’hich  he  has  to  do,  but  he  must  be  influenced  in  the  means  that  he 
adopts  by  the  constitutional  condition  of  the  patient,  by  the  t3q:)e  of  the 
inflammatory  fever,  and  b}^  the  state  of  the  diseased  part ;  for  nothing 
presents  greater  variety  than  the  management  of  the  inflammatoiy  pro¬ 
cess  in  different  conditions  of  the  patient,  and  in  the  different  phases  of 
that  affection.  We  shall  accordingl}^  consider  the  treatment  of  acute 
inflammation  as  applied  to  the  sthenic,  the  asthenic,  and  the  irritative 
varieties  of  the  disease. 

Treatment  of  Acute  Inflammation  with  Fever  of  the  Sthe¬ 
nic  Type. — In  the  treatment  of  this  varieW  of  the  disease,  active  and 
energetic  measures  must  earl^’  be  had  recourse  to,  especially  if  the  patient 
be  young  and  strong.  There  is  no  affection  that  is  more  under  the  con¬ 
trol  of  the  Surgeon  than  this  when' occurring  in  a  healthy  constitution, 
and  in  which  more  can  be  done  b}’’  active  means  early  employed.  It  is 
consequently  of  the  first  importance  that  precious  time  be  not  lost  b}^  the 
emplo^unent  of  inefficient  measures ;  otherwise  important  local  changes 
and  irremovable  alterations  of  structure  may  ensue.  It  is  also  of  great 
consequence  to  remove  the  disease  fully ;  not  only  to  subdue  it,  but  to 
extirpate  it,  lest  it  degenerate  into  some  of  the  more  chronic,  passive, 
and  intractable  forms. 

The  first  thing  to  be  attended  to  in  the  treatment  of  the  sthenic,  and 
of  all  the  other  varieties  of  inflammation,  is  the  removal  of  the  cause. 
Thus,  rest  must  be  afforded  to  a  diseased  joint,  light  withheld  from  an 
inflamed  eye,  and  a  foreign  body  taken  out  of  the  flesh  in  which  it  is 
lodged. 

The  next  great  indication  is  to  lessen  the  determination  of  blood  to 
the  part.  The  measures  for  accomplishing  this  comprise  what  is  termed 
the  antiphlogistic  treatment.  This  consists  of  constitutional  and  local 
means. 

Constitutional  Treatment. — The  most  powerful  and  efficient  means 
that  we  possess  is  certainly  Blood-letting :  and,  when  the  inflammation 
is  sufficientl}'’  extensive  and  severe,  and  the  patient’s  powers  warrant  it, 
we  may  have  recourse  to  the  abstraction  of  blood.  But,  as  blood  can 
easil}^  be  taken  away,  but  cannot  readily  be  restored,  we  should  never 
remove  it  unnecessarily,  lest  permanent  ill  effects  to  the  health  ensue. 
Blood-letting  is  certainly  not  often  required  in  the  treatment  of  surgical 
inflammations  ;  and  it  should  be  especially  avoided  in  very  young  and 
in  very  old  subjects,  in  the  inhabitants  of  large  towns  generally,  or  in 
those  in  whom  inflammation  of  a  specific  character  occurs.  It  should 
never  be  had  recourse  to  unless  an  organ  of  great  importance  to  the 


CONSTITUTIONAL  TEEATMENT. 


Ill 


economy,  as  the  lung  or  brain,  for  instance,  be  inflamed,  or  so  injured 
that  inflammation  of  it  is  imminent ;  or  unless  a  tissue,  like  the  trans¬ 
parent  structure  of  the  eye,  be  affected,  in  which  it  is  absolutely  neces- 
saiy,  at  any  risk,  to  cut  short  an  inflammation  before  it  gives  rise  to  a 
change  of  structure,  which,  however  slight,  would  be  fatal  to  the  utility 
of  the  part.  The  quantity  of  blood  that  should  be  taken  necessarily 
varies  greatl3",  according  to  the  age  and  constitution  of  the  patient,  and 
the  nature  of  his  disease ;  and  it  is  of  importance  to  bear  in  mind  that, 
when  blood-letting  is  required,  the  s^’stem  tolerates  the  loss  of  the  vital 
fluid  in  a  way  that  it  does  not  otherwise.  The  effect  produced  on  the 
pulse  and  on  the  system  should  be  the  guide  to  the  quantity  to  be  taken 
away.  A  decided  impression  should  be  produced  b^"  blood-letting,  not 
so  much  on  the  frequency  of  the  pulse  as  on  its  character ;  that  should 
guide  us,  and  not  to  the  number  of  ounces  drawn.  The  point  to  be 
obtained  is  the  greatest  effect  upon  the  system  with  the  least  loss  to  the 
patient ;  hence  the  blood  should  be  taken  from  a  large  oriflce  in  the 
median  basilic  or  the  cephalic  vein,  the  patient  sitting  upright.  In 
repeating  the  venesection,  we  must  be  guided  b}’- the  impression  that  has 
been  made  upon  the  disease,  and  by  the  state  of  the  pulse.  By  blood¬ 
letting,  when  it  is  indicated  by  the  severity  of  the  inflammation,  or  by 
the  importance  of  the  part  affected,  we  not  only  lessen  the  force  of  the 
circulation,  but  we  also  abstract  at  once  from  the  system  a  quantity  of 
blood  that  has  been  deteriorated  b}^  an  accumulation  of  the  products  of 
the  waste  of  tissues  in  it.  It  is  especially  in  those  forms  of  inflammation, 
therefore,  in  which  the  blood  is  earl}^  and  abundantly  charged  with  these 
products,  in  which  it  is  superfibrinated  to  a  great  extent,  as  in  inflam¬ 
mation  of  serous  membranes  and  of  fibrous  tissues,  that  blood-letting 
has  been  proved  by  experience  to  be  of  service. 

Whether  blood-letting  be  had  recourse  to  or  not,  we  must  endeavor  to 
set  the  secretions  free,  and  in  this  way  to  clear  the  blood  of  the  morbid 
products  accumulated  in  it.  If  we  can  bring  about  a  full  action  from 
the  liver  or  bowels,  with  copious  bilious  evacuations,  abundant  secretion 
of  acid  perspiration  from  the  skin,  or  a  copious  discharge  of  urine  loaded 
with  lithates,  we  shall  often  at  once  cut  short  the  disease.  With  these 
views  purgatives^  diaphoretics^  and  diuretics  are  to  be  administered. 

Purgatives  should  always  be  given  earl}^,  except  in  some  special  cases 
of  acute  inflammation  of  the  abdominal  oro-ans.  They  clear  the  intes- 

O  */ 

tinal  canal,  free  the  secretions,  and  equalize  the  circulation.  In  general, 
it  will  be  found  most  advantageous  to  administer  a  mercurial,  followed 
by  a  brisk  saline  purge  ;  and  this  should  be  repeated  from  time  to  time 
during  the  progress  of  the  case. 

Diuretics  and  diaphoretics  require  to  be  administered  frequentl}-"  during 
the  da3^  If  the  skin  be  hot  and  diy,  antimonials  should  be  given  in 
small  and  repeated  doses;  these  may  advantageousl3"  be  conjoined  with, 
or  replaced  b3^  salines,  such  as  the  citrate  of  potass,  the  acetate  of  ammo¬ 
nia,  or  nitre.  In  this  way  the  force  of  the  heart’s  action  is  lessened,  and 
the  skin  and  kidne3"s.  are  called  into  active  operation.  It  is  also  probable 
that  the  salines  alter  the  constitution  of  the  blood,  dissolving  the  fibrine 
and  lessening  the  quantit3’  of  water,  both  of  which  constituents  are  in 
excess  in  inflammation. 

Aconite  in  small  doses  frequentl3"  repeated — one  minim  of  the  tincture 
eveiy  half  hour  for  four  hours  and  then  eveiy  hour — exercises  a  most 
marked  influence  on  simple  inflammatoiy  fever  when  there  are  no  visceral 
complications.  It  lowers  the  force  and  frequenc3’  of  the  pulse,  and  pro¬ 
duces  speedy  and  copious  sweating,  to  the  infinite  relief  of  the  patient. 


112 


INFLAMMATION. 


In  man}"  forms  of  sthenic  inflammation,  especially  in  those  which  affect 
the  serous  and  fibrous  membranes,  we  do  not  possess  a  more  efficient 
agent  than  mercury^  administered,  not  as  a  purgative,  but  as  an  alte¬ 
rative  to  the  S3’stem.  And  I  confess  that  I  can  in  no  way  give  my  adhe¬ 
rence  to  the  doctrines  of  those  who,  disregarding  the  dail}"  evidence  of 
professional  experience,  deny  the  utilit}"  of  the  preparations  of  this 
mineral  in  the  treatment  of  certain  forms  of  inflammatory  disease.  Mer¬ 
curial  remedies  are  of  special  service  in  aiding  the  operation  of  other 
medicines.  Diuretics,  diaphoretics,  and  purgatives,  will  frequently  not 
act  properly  unless  conjoined  with  a  mercurial.  In  inflammation,  the 
preparations  of  mercury  act  as  direct  antiphlogistic  agents,  lessening  the 
quantit}"  of  fibrine  in  the  blood,  and  equalizing  the  circulation.  They 
are  of  special  value  in  promoting  the  absorption  of  exudation-matters, 
more  especially  of  lymph,  as  we  may  see  happening  under  their  influence 
in  certain  diseases  of  the  e3"e.  The}"  appear  to  do  this  rather  b}"  lowering 
the  vascular  action  of  the  part,  and  thus  allowing  the  absorption  to  be 
carried  on,  which  had  been  arrested  during  the  persistence  of  the  inflam¬ 
mation,  than  b}"  an}"  specific  influence  exercised  over  the  effused  fibrine. 
Care,  however,  is  required  in  the  administration  of  mercury.  In  irritable 
or  cachectic  constitutions  it  should  not  be  given  at  all,  or  not  without 
great  caution.  It  is  best  borne  by  strong  constitutions,  and  in  acute 
inflammation  of  the  serous  and  fibrous  tissues. 

Calomel,  blue  pill,  and  mercury  and  chalk,  are  the  preparations  usually 
employed  when  the  mineral  is  given  by  the  mouth.  When  it  is  admin¬ 
istered  endermically,  the  mercurial  ointment  is  preferred ;  and  the  use 
of  the  mineral  is  in  general  continued  until  the  gums  become  spongy, 
and  a  red  line  is  formed  at  their  edge  ;  the  patient  experiencing  a  cop¬ 
pery  taste  in  the  mouth,  and  the  breath  becoming  fetid.  It  is  not  neces¬ 
sary  to  induce  profuse  salivation. 

It  is  especially  the  combination  of  calomel  with  opium  that  produces 
the  most  beneficial  effects  in  the  treatment  of  active  surgical  inflam¬ 
mation.  Two  grains  of  calomel,  and  half  a  grain  or  a  grain  of  opium, 
or  five  grains  of  Dover’s  power  with  three  of  mercury  and  chalk,  every 
fourtli  or  sixth  hour,  tranquillize  the  system  and  lessen  vascular  action 
in  a  remarkable  manner,  especially  in  acute  inflammation  affecting  the 
jaws,  the  eye,  or  the  serous  membranes. 

Opium  is  not  only  of  use  in  the  way  that  has  just  been  indicated,  but 
is  of  essential  service  in  allaying  the  pain  and  irritability  that  often 
accompany  inflammation,  especially  in  many  inflammatory  affections  of 
the  bones  and  joints.  In  the  form  of  Dover’s  powder,  it  is  of  especial 
value  in  this  respect. 

In  the  treatment  of  acute  inflammation,  it  is  of  essential  consequence 
that  the  patient  should  be  kept  at  rest,  in  a  well-regulated  temperature, 
and  on  low  diet ;  in  fact,  the  more  complete  the  abstinence  in  this  respect 
is,  the  more  rapidly  do  therapeutic  means  act  and  the  febrile  symptoms 
cease. 

lioeal  Treatment. — This  is  of  the  utmost  importance,  as  it  directly 
influences  the  tissues  and  vessels  that  are  deranged  in  action.  It  con¬ 
sists  of  means  of  the  most  varied  and  opposite  characters.  Heat  and 
cold  ;  iced  water  and  hot  fomentations;  astringents  and  sedatives — are 
all  employed,  and  all  with  success,  but  each  only  in  certain  stages  and 
forms  of  the  disease ;  and  the  art  in  conducting  the  local  treatment  of 
inflammation  consists  in  adapting  the  various  means  at  our  disposal  to 
the  particular  condition  of  the  case  before  us. 

Local  Blood-letting  is  the  most  efficient  means  we  possess  in  directly 


LOCAL  TREATMENT. 


113 


lessening  vascular  action  in  a  part,  as  b}"  it  we  take  the  blood  directly 
from  the  inflamed  and  turgid  vessels.  It  may  be  used  in  addition  to, 
though  it  is  now  very  commonl}'’  employed  in  preference  to,  general 
blood-letting:  especially  if  the  inflammation  be  not  severe,  or  if  it  occur 
at  either  of  the  extremes  of  life,  in  w'omen,  and  in  persons  generally 
of  feeble  power. 

Blood  may  be  taken  locally  hy  punctures^  scarifications^  or  incisions, 
or  by  leeching  or  cupping. 

Punctures  and  incisions  can  only  be  practised  in  inflammation  of  the 
cutaneous  and  exposed  mucous  surfaces,  due  attention  being  had  to 
subjacent  parts  of  importance.  They  constitute  a  very  efficient  means 
of  relief  to  the  parts,  as  not  only  is  blood  removed,  but  an  exit  is  afforded 
for  effused  matters;  tension  is  consequently  materially  lessened,  and  the 
tendency  to  sloughing  and  other  evil  after-consequences  perhaps  pre¬ 
vented.  The  removal  of  the  tension  of  inflamed  parts  is  not  only  of  the 
greatest  advantage  locallj^,  but  is  of  considerable  service  to  the  system 
at  large  by  lessening  the  pain  and  general  irritation  that  are  always 
occasioned  by  it.  The  punctures  should  be  made  with  a  fine  lancet, 
in  parallel  rows  over  the  inflamed  surface,  and  should  not  exceed  a 
quarter  of  an  inch  in  depth.  The  incisions  must  always  be  made  in  the 
axis  of  the  limb,  and  should  be  so  arranged  as  to  afford  the  greatest 
possible  relief  to  the  tension  of  the  parts.  Their  superficial  extent  and 
their  depth  must  vary  according  to  the  seat  of  the  inflammation.  Thus 
in  the  inflamed  conjunctiva  they  must  of  course  be  very  limited,  whilst 
in  phlegmonous  inflammation  of  a  limb  they  may  be  of  much  greater 
extent  and  depth.  Care  must  be  taken  as  far  as  possible  not  to  wound 
superficial  arteries  or  veins.  A  modification  of  puncture  is  sometimes 
practised  b}’’  opening  the  veins  in  the  neighborhood  of  the  inflamed 
part  at  several  points  at  once.  Thus,  in  inflammation  of  the  testis  the 
scrotal  veins  may  advantageously  be  punctured.  The  bleeding  from 
punctures  and  incisions  should  be  encouraged  by  warm  fomentations. 

Leeches  are  usefully  applied  to  the  neighborhood  of  inflamed  parts, 
but  should  not  be  put  iqjon  the  inflamed  surface  itself,  as  their  bites 
irritate.  There  are  certain  situations  in  which  leeches  should  not  be 
placed,  as  over  a  large  subcutaneous  vein,  or  in  regions  where  there  is 
much  areolar  tissue,  as  the  scrotum  or  eyelids,  lest  troublesome  hemor¬ 
rhage  or  ecchymosis  result.  So,  also,  they  should  not  be  applied  near  a 
specific  ulcer,  lest  their  bites  become  inoculated  bj'-  the  discharge.  The 
bleeding  from  a  leech-bite  should  be  encouraged  by  warm  poulticing  or 
fomentations  for  some  time  after  the  animal  has  dropped  off.  In  this  way 
from  half  an  ounce  to  an  ounce  of  blood  may  be  taken  by  each  leech. 
There  is  usually  no  difficulty  in  arresting  the  hemorrhage  from  the  bite ; 
should  there  be  any,  continued  pressure  with  some  scraped  lint,  felt, 
matico,  or  powdered  alum,  will  accomplish  this.  If  this  do  not  succeed, 
which  may  happen  in  some  situations  where  iDressure  cannot  be  con¬ 
veniently  applied,  as  on  the  neck  and  abdomen,  particularly  in  young 
children,  a  piece  of  nitrate  of  silver  scraped  to.  a  point,  or  a  heated  wire 
introduced  into  the  bite,  previously  wiped  dry,  or  a  twisted  suture  over 
and  around  it,  may  be  required. 

Cupping  is  the  most  efficient  local  means  of  removing  blood  that  we 
possess,  and  the  quantity  extracted  may  be  regulated  to  a  nicet}^  in  this 
way.  It  cannot,  however,  be  emplo^^ed  upon  the  inflamed  surface  itself, 
on  account  of  the  pain  and  irritation  that  would  be  occasioned,  and  is  con¬ 
sequently  chief!}"  applicable  to  internal  inflammations.  As  the  scars  made 

VOL.  I. — 8 


114 


IXFLAM  MATION. 


b}'  the  scarificators  continue  through  life,  cupping  should  not  be  prac¬ 
tised  upon  exposed  surfaces. 

Cutting  off  the  Supply  of  Blood  from  the  inflamed  part  b}^  the  ligature 
of  the  main  artery  leading  to  it  has  been  adopted  in  some  cases.  Thus, 
in  acute  inflammation  of  a  joint,  the  main  artery  of  the  limb  has  been 
tied ;  the  femoral,  for  instance,  in  inflammation  of  the  knee-joint.  By 
many  Surgeons  and  by  most  patients,  the  remedy'  would  be  considered  . 
far  worse  than  the  disease  for  the  cure  of  which  it  is  proposed. 

Yanzetti  has  recommended  digital  pressure  on  the  arteries  in  inflam¬ 
mation.  He  has,  for  instance,  related  a  case  of  severe  acute  inflam¬ 
mation  of  the  hand,  relieved  b}’  twent3’-four  hours’  continuous  pressure 
on  the  brachial  arteiy.  Xeudorfer  speaks  highl}’  of  the  proceeding, 
which  he  regards  as  surpassing  in  efficac}’  all  other  means,  and  even 
rendering  unnecessaiy  the  ordinaiy  antiphlogistic  treatment.  He  recom¬ 
mends  intermittent  pressure  for  not  less  than  three  and  not  more  than 
eight  minutes  three  or  four  times  a  da}".  The  method  is  applicable  to 
inflammation  of  any  part  of  which  the  artery  is  within  reach;  and  though 
we  may  not  go  so  far  with  Xeudorfer  as  to  suppose  that  it  obviates  all 
necessity  for  constitutional  treatment,  it  appears  to  be  a  remedy  far  pre¬ 
ferable  to  local  blood-letting. 

In  Gold  and  Heat  we  possess  two  most  important  local  means  of  con¬ 
trolling  inflammation.  They  cannot,  however,,  be  employed  indiscrimi¬ 
nately. 

Cold. — There  are  two  stages  of  inflammation  in  which  cold  may  be 
employed  with  especial  advantage;  first,  during  the  very  early  and  acute 
stage,  rather  with  a  view  of  preventing  or  limiting  the  inflammation,  so 
that  it  may  not  pass  beyond  the  bounds  of  adhesive  action  ;  and  next, 
when  acute  inflammation  has  passed  ofi‘,  the  vessels  of  the  part  remain¬ 
ing  relaxed  and  turgid  ;  the  application  of  cold  being  a  powerful  agent 
in  restoring  the  tone  of  the  parts. 

Cold  should  never  be  had  recourse  to  between  these  stages,  when  sup¬ 
puration  is  coming  on,  or  has  set  in;  still  less  should  it  be  employed  when 
there  is  a  tendency  to  mortification.  Its  long-continued  and  incautious 
use  may  indeed  be  followed  by  profuse  suppuration  or  extensive  slough¬ 
ing  of  the  inflamed  part. 

The  modes  of  applying  cold  vary  according  to  the  part  aflected  and 
the  stage  of  the  inflammation.  In  the  early  and  acuter  stage,  and  if  the 
surface  be  inflamed,  evaporating  spirit  lotions,  to  which  sedatives  may 
sometimes  be  advantageously  added,  are  the  best.  If  it  be  wished  to 
influence  the  whole  substance  of  a  limb,  irrigation  with  cold  water 
should  be  adopted  (Fig.  57).  If  it  be  intended  that  the  effect  of  the 
cold  penetrate  deeply,  as  in  inflammations  of  joints,  of  the  head,  spine, 
or  chest,  it  may  be  applied  by  means  of  pounded  ice.  The  ice  is  best 
applied  by  being  placed  in  a  bladder,  gut,  or  a  Mackintosh  bag,  par¬ 
tially  filled.  Esmarch  has  especially  pointed  out  the  great  advantage 
of  using  ice  in  an  India-rubber  bag,  which  always  remains  dry,  and  from 
the  use  of  which  no  danger  from  frostbite  is  to  be  apprehended,  as  may 
occur  from  the  long-continued  use  of  cold  and  wet  applications.  With 
the  view  of  removing  the  congestion  consecutive  on  inflammation,  cold 
douching  or  sponging  is  most  efficacious. 

Warmth  and  moisture  conjoined  are  of  the  utmost  service  in  the  treat¬ 
ment  of  inflammation  during  the  height  of  that  process — during  that 
period  when  cold  applications  are  not  admissible.  By  these  means, 
tension  is  relaxed,  effusion  is  favored,  and  thus  the  over-distended  vessels 
are  relieved.  If  continued  for  too  long  a  time,  however,  these  means 


TREATMENT  OF  ASTHENIC  INFLAMMATION. 


115 


favor  congestion,  and  sodden  the  parts.  Warm  applications  are  espe¬ 
cially  serviceable  in  all  cases  of  inflammation  attended  b^'  much  pain, 
more  particular!}'  if  this  occur  from  tension  ;  and  they  are  especially 
useful  when  suppuration  is  threatening,  or  has  come  on,  and  in  many 
cases  where  there  is  a  tendency  to  slough. 

When  abscess  threatens,  or  the  surface  is  broken,  nothing  affords  so 
much  relief  as  a  well-made  poultice,  either  of  linseed-meal  or  of  iu’ead  ; 
this,  made  soft  and  smooth,  and  not  spread  too  thickly  on  the  cloth  con¬ 
taining  it,  should  be  applied  as  hot  as  the  patient  can  bear  it. 

Water-dressing^  consisting  of  double  lint,  well  soaked  in  tepid  water, 
and  covered  by  oiled  silk,  or  thin  gutta-percha,  extending  from  half  an 
inch  to  an  inch  beyond  it  on  all  sides,  may  be  advantageously  substi¬ 
tuted  for  a  poultice,  if  the  sore  be  small,  and  the  inflammation  limited. 

Fomentations  of  warm  water,  or  of  decoction  of  poppy  and  camomile 
flowers,  applied  by  means  of  flannels  wrung  out  of  these  liquids,  or  of 
bags  containing  the  boiled  plants,  well  soaked  in  the  decoction,  squeezed 
out,  and  applied  hot,  are  very  useful  in  extensive  superficial  infiamma- 
tions.  The  flannels  and  bags  should  be  well  covered  with  oiled  silk  or 
Mackintosh  cloth,  so  as  to  retain  the  heat,  and  to  prevent  evaporation. 
Spongio-piline  may  be  used  as  a  substitute  for  ordinary  fomentations  in 
cases  in  which  the  surface  is  unbroken. 

applied  externally  exercises  a  very  distinct  and  rapid  con¬ 
trolling  influence  over  superficial  inflammation  of  an  acute  character. 
The  extract,  softened  with  water,  and  moistened  with  glycerine,  may  be 
painted  on  the  inflamed  part,  or  a  strong  solution  of  it  added  to  the 
fomentations  with  the  greatest  advantage. 

Position. — The  inflamed  part  should  always  be  placed  in  such  a  posi¬ 
tion  as  to  facilitate  the  return  of  blood  from  it.  Unless  this  be  done,  the 
pain  is  greatly  increased,  and  the  congestion  augmented.  Hence  the 
part  requires  to  be  elevated  on  a  level  with,  or  above,  the  rest  of  the 
body.  All  motion  and  use  must  likewise  be  interdicted,  as  favoring 
determination  and  increasing  pain. 

These  are  the  means  by  which  acute  active  inflammation  is  arrested 
and  cured.  In  their  employment,  we  must  endeavor  to  proportion  the 
activity  of  our  measures  to  the  age,  constitution,  and  vigor  of  the 
patients,  and  to  the  seat  and  intensity  of  the  local  disease  ;  and  must 
continue  the  treatment  until  the  inflammatory  action  is  not  only  arrested, 
but  has  entirely  subsided,  the  part  being  restored  to  its  ordinary  healthy 
state. 

Treatment  of  Acute  Inflammation  with  Constitutional 
Symptoms  of  the  Asthenic  and  Irritative  Types. — The  asthenic 
and  irritative  forms  of  inflammation  derive  tlieir  peculiarities  from  the 
character  of  the  constitutional  disturbance,  rather  than  from  any  pecu¬ 
liarity  in  the  local  affection.  Hence  it  is  in  the  management  of  the 
constitutional  condition,  that  the  principal  difference  exists  between  the 
treatment  of  these  and  that  of  the  other  varieties  of  acute  inflam¬ 
mation. 

In  considering  this  part  of  our  subject,  it  is  of  especial  importance  to 
banish  the  term  “  anti-inflammatory ;  ”  for  the  same  treatment  that 
would  arrest  inflammation  in  one  form  of  the  disease,  w'ould  certainlv 
favor  its  progress  in  another.  Xothing  appears  to  me  to  be  more  unsci¬ 
entific  than  to  endeavor  to  treat  all  inflammations  on  one  uniform  plan. 
Surely  the  scoffers  at  medical  science  have  some  ground  for  doubting  at 
least  the  wisdom  of  its  Professors,  w'hen  they  see  one  set  of  practitioners 
treating  every  inflammatory  disease  with  depletion,  antimony,  and  calo- 


116 


INFLAMMATION. 


mel,  whilst  others  teach  that  the  panacea  for  all  inflammations  consists 
in  brandy,  ammonia,  and  bark.  It  is  impossible  that  both  methods  can 
be  right,  as  exclusive  plans  of  treatment.  But  the  error  lies  in  making 
them  exclusive.  Each  is  serviceable,  and  indeed  alone  applicable  in  its 
own  particular  cases.  And  between  these  extremes  lie  a  multitude  of 
forms  of  disease,  in  which  endless  modifications  and  combinations  of 
these  two  methods  of  treatment — the  stimulating  and  the  depletory — 
must  be  adopted  by  the  Surgeon  in  order  to  meet  the  varying  conditions 
of  his  patient.  The  local  symptoms  that  constitute  the  inflammatory 
process,  whether  occurring  externally  or  internally,  in  the  conjunctiva 
or  in  the  lung,  are  associated  with  constitutional  disturbance  that  varies 
according  to  the  age  and  the  constitutional  condition  of  the  patient.  It 
is  the  type  that  is  affected  by  this  constitutional  disturbance,  its  sthenic 
or  its  adynamic  character,  as  indicated  by  the  pulse  and  by  the  tongue, 
and  not  the  mere  diagnosis  of  the  local  disease,  that  must  guide  the 
Surgeon  in  the  adoption  of  his  line  of  practice.  We  may  advantage¬ 
ously  treat  with  antimony  and  bloodletting  acute  inflammation  of  the 
conjunctiva,  or  that  which  is  the  consequence  of  a  wmund  of  the  lung, 
in  an  otherwise  healthy  and  robust  man  of  thirty ;  whilst  in  a  broken 
man  of  seventy,  ammonia,  bark,  port  wine,  and  brandy  would  be  equally 
proper ;  but  if  we  were  (except  under  peculiar  and  exceptional  circum¬ 
stances)  to  reverse  this  treatment — to  stimulate  the  young  or  vigorous, 
and  to  deplete  the  aged  or  feeble — we  should  act  contrary  to  common 
sense,  and  probably  destroy  rather  than  cure  our  patients.  It  is  of  far 
greater  importance  to  be  able  to  estimate  accurately  the  true  constitu¬ 
tional  condition  of  the  patient,  than  to  be  able  to  form  a  minute  diag¬ 
nosis  of  the  precise  seat,  extent,  and  depth  of  the  local  mischief.  It  is 
a  fatal  error,  too  often  committed,  to  attach  too  much  consequence  to 
the  recognition  of  the  local  malady,  and  too  little  importance  to  the 
character  of  the  constitutional  disturbance  attending  it.  The  Surgeon 
who  acts  thus*  runs  the  risk  of  treating  the  Name  and  not  the  Disease. 
If  we  treat  eiysipelas  or  pneumonia  as  mere  affections  of  the  skin  or 
lung,  on  one  uniform  plan,  without  reference  to  the  type  of  the  consti¬ 
tutional  disturbance  accompanying  them,  we  shall  miserably  err  in  a 
considerable  proportion  of  the  cases.  But  if,  paying  but  little  attention 
to  the  local  affection,  except  so  far  as  its  characters  indicate  the  general 
type  of  the  disease,  we  make  the  constitution  of  our  patient  our  guide, 
and  deplete  or  stimulate  according  to  tlie  state  in  which  we  find  it,  and 
thus  perhaps  treat  two  patients  with  the  same  disease,  so  far  as  name 
is  concerned,  on  totally  opposite  plans,  we  shall  not  act  inconsistently 
but  in  strict  conformity  with  the  natural  condition  of  the  patient  and  of 
his  disease. 

We  must  be  entirely  guided  in  the  means  that  we  adopt  by  the  con¬ 
dition  of  the  patient,  the  state  of  the  tongue  and  pulse,  and  the  general 
character  of  the  symptoms.  If  these  from  the  first  partake  of  the  asthenic 
or  irritative  type,  we  cannot  at  any  period  have  recourse  to  the  treatment 
that  has  been  recommended  in  sthenic  inflammation.  If  the  disease 
commences  in  an  active  form,  the  fever  progressively  assuming  a  lower 
and  lower  character,  merging  into  the  asthenic  and  irritative  types,  so 
must  we  gradually  alter  the  nature  of  our  general  treatment ;  and  this 
is  alwaj^s  a  delicate  procedure,  requiring  much  caution.  Though  the 
inflammatory  fever  may  at  first  assume  the  sthenic  form,  if  there  be 
reason  to  believe,  from  the  broken  constitution  of  the  patient,  or  from 
the  congestive  or  passive  character  of  the  local  inflammation,  that  the 
constitutional  s3^mptoms  will  not  long  continue  of  this  type,  we  must  be 


TREATMENT  OF  ASTHENIC  INFLAMMATION. 


117 


extremely  cautious  how  we  lower  the  j^atient  active  depletion ;  for, 
however  high  the  fever  may  at  first  run  (and  in  these  cases  there  is  often 
febrile  disturbance  of  a  very  active  character  for  the  first  few  days),  the 
disease  speedily  expends  its  force  and  rapidly  subsides  into  a  low  form. 
In  cases  of  this  kind,  which  are  of  veiy  common  occurrence  in  London 
practice,  more  particularly  in  hospitals,  we  should  never  bleed, but  content 
ourselves,  after  clearing  out  the  bowels,  with  keeping  the  patient  quiet 
on  a  moderately  low  diet,  and  administering  diaphoretic  salines.  As  the 
sj'mptoms  gradually  merge  into  the  typhoid  type,  the  pulse  with  increas¬ 
ing  frequency  diminishing  in  power,  the  tongue  becoming  dry  and  dark, 
and  the  other  S3^mptoms  of  asthenia  beginning  to  show  themselves,  we 
must  beojin  to  give  some  stimulant  in  combination  with  the  salines.  The 
carbonate  of  ammonia  in  five  or  ten  grain  doses,  or  even  more,  ma^*  be 
given  with  bark,  or  in  an  effervescent  form  with  fifteen  grains  of  the 
bicarbonate  of  potass  and  a  sufficient  quantity"  of  citric  acid,  eveiy  third 
or  fourth  hour.  The  nourishment  must  be  increased ;  and  wine  or 
alcoholic  stimulants  must  be  conjoined  with  it,  in  proportion  as  the  s^unp- 
tonis  of  debility  become  more  and  more  urgent.  In  effecting  this  change, 
we  must  be  careful  not  to  run  into  the  error  of  overstimulating  our 
patient ;  this  may  be  avoided  bj^  observing  the  influence  exercised  on 
the  pulse  and  tongue  by  the  ehange  in  treatment. 

In  the  majority  of  cases,  this  stimulating  plan  is  not  well  borne  during 
the  first  few  da3^s  after  the  setting  in  of  an  inflammation,  especialty  if 
there  be  gastric  irritation  and  sickness;  but  when  the  more  active  S3’mp- 
toms  show  a  tendency  to  subside,  when  the  bowels  have  been  well  cleansed 
out,  and  the  skin  is  beginning  to  assume  a  slight  degree  of  moisture, 
then  it  may  be  resorted  to  with  eveiy  probability  of  success. 

In  man3^  cases,  however,  it  happens  that  the  s3’mptoms  so  rapidh'  sink 
into  or  from  the  veiy  first  assume  an  asthenic  character,  that  the  onty 
treatment  which  holds  out  a  chance  of  saving  the  patient’s  life  consists 
in  the  early  and  free  administration  of  tonics  and  stimulants,  with  mild 
nourishment,  such  as  ammonia  and  bark,  wine,  brand3q  or  porter,  with 
beef-tea  and  arrowroot ;  and  of  these  large  quantities  may  be  required 
in  the  four-and-twenty  hours,  the  patient  evincing  a  tendency  to  sink 
whenever  their  use  is  interrupted.  Although  stimulants  be  freely  admin¬ 
istered  in  these  cases,  the  food  should  be  bland  and  capable  of  easy  assi¬ 
milation.  It  is  worse  than  useless  to  give  meat,  etc.,  when  the  patient 
cannot  digest  it ;  but  beef-tea,  eggs,  and  farinaceous  food,  may  be  given 
in  large  quantities  with  advantage.  The  brand3'-and-egg  mixture  of  the 
Pharmacopoeia,  if  well  made,  combining  nutriment  and  stimulus,  is  the 
best  remed3"  that  can  be  administered  in  maiy^  cases  of  low  inflammation. 

Under  this  plan  of  treatment  the  tongue  will  be  found  to  become  moist, 
the  brown  sordes  to  clear  off  from  the  inside  of  the  mouth,  the  pulse  to 
become  stead3"  and  full,  sleep  to  be  procured,  and  the  strength  maintained. 
The  more  I  see  of  surgical  inflammation,  the  more  confidence  do  I  feel 
in  this  stimulating  plan  of  treatment,  which  is  the  onty  method  of  car¬ 
rying  patients  through  those  low  forms  of  visceral  inflammation  that  are 
so  frequent  in  hospital  practice.  The  liability  to  these  inflammations 
will  also  be  materialty  lessened  b3"  the  earty  emplo3"ment  of  a  stimulating 
plan  of  treatment  after  injuries  and  operations. 

As  the  asthenic  passes  into  the  irritative  form,  we  ma3^  find  it  neces¬ 
sary  to  conjoin  opiates  with  the  general  treatment. 

In  the  low  forms  of  inflammatoiy  fever,  congestive  pneumonia  and 
asthenic  bronchitis  frequently  supervene.  In  this  complication,  the  fol¬ 
lowing  draught  ma3^  be  advantageousty  given  eveiy  third  or  fourth 


118 


INFLAMMATION. 


hour:  R.  Tincturse  Camphorae  comp,  up  xx*  ad  xxx.,  Ammoniae  Carboiiatis 
gr.  V.  ad  X.,  Decocti  Seiiegae^  iss.  Rubefacients,  blisters,  or  dry  cupping 
may  also  be  applied  to  the  chest.  The  diarrhoea  that  not  unfrequently 
occurs  must  be  met  witli  opiates  and  astringents  ;  and  if  the  urine  cannot 
be  passed,  it  must  be  drawn  off  by  the  catheter. 

CHRONIC  INFLAMMATION. 

The  preceding  description  is  principally  applicable  to  acute  inflamma¬ 
tion  ;  and  it  now  remains  to  give  a  brief  summary  of  the  distinctive 
characters  of  the  chronic  form  of  the  disease,  and  to  describe  its 
treatment. 

Pathology. — In  acute  inflammation,  the  changes  that  take  place  on 
the  part  of  the  vessels  and  in  the  blood  are  strongly  marked  and  more 
or  less  rapid  in  occurrence;  and  the  modifications  of  nutrition  which 
the  part  undergoes  are  mostl}^  of  a  temporary  character,  and  hold  a 
secondary  relation  in  point  of  importance  to  the  other  conditions.  In 
chronic  inflammation,  on  the  other  hand,  the  changes  in  the  nutrition  of 
the  part  form  the  principal  treatment.  Billroth,  in  describing  chronic 
inflammation,  sa3^s  :  “  The  distension  of  the  capillaiy  vessels,  or  fluxion, 
is  a  less  prominent  symptom,  while  the  new  formation  of  tissue  and 
serous  infiltration  seem  to  play  a  more  prominent  role.  The  cell-infil¬ 
tration  of  the  tissue  takes  place  in  few  cases,  as  it  does  in  acute  inflam¬ 
mation  ;  but  the  individual  cells  often  attain  a  rather  more  complete 
development.  In  this  j^rocess  of  development  the  intercellular  tissue 
changes;  the  connective  tissue  filaments  lose  their  tough  filamentary 
consistenc}^,  the  distensibility  and  elasticity  of  the  subcutaneous  tissue 
are  impaired,  and  the  consequence,  as  regards  the  coarser  palpable  and 
visible  consequences,  is  that  the  tissue  becomes  more  swollen  and  fatty, 
and  less  movable  than  normal.  This  is  the  first  stage  of  every  chronic 
inflammation.” 

Phenomena. — Regarding  the  modifications  of  color,  size,  sensation, 
function,  and  temperature,  described  as  attendant  on  acute  inflammation, 
it  is  to  l3e  observed  that  the}"  are  also  present  in  chronic  inflammation  ; 
differing,  however,  in  degree  and  in  origin,  and  often  in  order  and  com¬ 
bination.  The  color  is  not  always  changed,  unless  the  part  affected  be 
very  superficial;  and  the  redness  is  rather  of  the  dull  than  of  the  bright 
hue,  not  depending  on  the  rapid  transmission  of  an  increased  quantity  of 
bright  blood,  but  rather  on  a  congestive  condition.  The  affected  tissue 
may  become  permanently  colored,  probably  by  the  escape  of  large  num¬ 
bers  of  red  blood-corpuscles  through  the  walls  of  the  vessels,  and  the 
retention  of  their  pigmentary  matter  after  the  removal  of  the  more  fluid 
parts  of  the  effusion.  The  pain  is  less  frequent  of  the  spontaneously 
acute  character,  but  partakes  more  often  o-f  the  character  of  tenderness, 
being  elicited  by  pressure :  sometimes,  however,  it  is  very  severe.  The 
increase  of  temperature  is  but  slight. 

Swelling  is  an  early  and  most  important  sign  in  chronic  inflammation. 
It  depends  less  on  the  enlargement  of  the  vessels  than  on  the  effusion 
which  takes  place,  and  the  changes  in  which  may  be  said  to  constitute 
the  distinctive  characteristic  of  the  disease.  The  effused  material  con¬ 
sists  partly  of  serum  and  partly  of  plastic  matter.  The  former  may 
become  absorbed  ;  or,  in  serous  membranes,  may  remain  distending  them, 
as  in  the  joints.  The  plastic  matter  is  liable  to  remain,  and  to  lead  to 
hypertrophy,  or  thickening  and  induration  of  the  part. 

Like  acute  inflammation,  the  chronic  form  of  the  disease  may  be  at- 


TREATMENT  OF  CHRONIC  INFLAMMATION. 


119 


tended  with  suppuration.  This  will  be  described  in  the  next  chapter. 
(Pages  128  and  129.) 

In  chronic  inflammation  of  mucous  or  serous  membranes,  there  may 
be  an  increase  with  modification  of  the  secretion ;  producing,  in  the  case 
of  the  mucous  membranes,  the  condition  known  as  chronic  catarrh. 

Constitutional  Symptoms. — These  are  less  marked  in  chronicThan 
in  acute  inflammation  ;  but,  if  the  disease  assume  an  acute  character,  one 
of  the  forms  of  inflammatory  fever  already  described  may  appear.  The 
patient’s  health,  however,  is  in  most  cases,  impaired ;  being,  in  many 
instances,  affected  with  some  constitutional  taint  which  has  had  its  influ¬ 
ence  in  Droducing  or  maintaining  the  chronic  character  of  the  inflam- 
mation.  If  an  important  organ  be  affected,  or  if  the  chronic  inflam¬ 
mation,  though  afiecting  parts  not  essential  to  life,  be  very  extensive, 
the  pulse  will  be  found  to  be  habitually  above  the  normal  standard,  and 
exacerbations  of  fever,  often  of  a  distinctly  periodic  character,  develop 
themselves. 

Causes. — Chronic  inflammation  ma}’’  arise  from  the  presence  of  some 
local  irritation,  which,  if  temporary,  would  produce  acute  inflammation 
only,  but,  b}-  its  permanence,  produces  the  continuance  of  a  diseased 
condition.  It  is  speciall}'  liable  to  occur  in  some  constitutions,  as  the 
scrofulous ;  indeed,  certain  forms  of  chronic  inflammation,  as  of  the 
glands  and  joints,  are  veiy  common  in  scrofulous  subjects. 

Treatment. — The  treatment  of  chronic  inflammation  is  far  more 
diflflcult,  and  requires  much  more  attention,  than  that  of  the  acute  form 
of  the  disease.  Chronic  inflammation  is  so  frequently  complicated  with 
various  unhealthy  conditions  of  the  system,  and  with  an  impaired  state 
of  the  general  health,  by  which,  indeed,  it  is  often  kept  up,  that  much 
practical  tact  and  skill  are  required  in  carr3dng  out  the  therapeutic  indi¬ 
cations  properly. 

Constitutional  Treatment  of  Chronic  Inflammation. — In  the 
treatment  of  chronic  inflammation  we  have  not  so  much  to  subdue  inflam¬ 
matory  action,  as  to  remove  structural  changes  and  other  effects  induced 
b}’'  it.  Hence,  our  object  is  not  to  produce  a  great  and  sudden  impres¬ 
sion  on  the  system,  as  we  are  often  required  to  do  in  the  treatment  of 

the  acute  affection.  It  is  not  in  this  wav  that  chronic  inflammation  can 

_  */ 

ever  be  cured,  or  its  efiects  removed.  The  patient  might  be  bled  to  death, 
and  still  the  diseased  action  would  go  on  in  the  inflamed  part,  so  long 
as  there  was  a  drop  of  blood  circulating  in  his  vessels.  It  is  true  that 
the  same  antiphlogistic  means  are  emplo^^ed  in  arresting  the  chronic  as 
in  catting  short  the  acute  form  of  the  disease,  but  they  are  used  in  a  less 
energetic  manner:  our  object  being  to  induce  a  gradual  and  continuous 
improvement  in  the  state  of  the  system  and  of  the  diseased  part.  Local 
nutrition  is  always  deeply  modified  in  chronic  inflammation ;  and  it  can 
onl}^  be  restored  to  its  normal  condition  bj'  improving  the  patient’s 
general  health,  as  well  as  by  producing  an  impression  on  the  part  itself 
by  appropriate  topical  means.  Hence,  in  the  treatment  of  chronic 
inflammation,  hygienic  measures  are  of  the  first  consequence.  In  most 
cases,  nothing  can  be  done  without  proper  attention  to  these ;  and  much 
can  be  done  b}’  these  that  cannot  be  effected  by  any  more  direct  medi¬ 
cinal  means.  The  treatment  of  this  form  of  inflammation  must  likewise 
be  varied  according  as  it  is  uncomplicated,  occurring  in  an  otherwise 
healthy  constitution,  and  assuming  a  sthenic  t3q3e ;  or  as  it  occurs  in  a 
cachectic  and  feeble  system,  assuming  a  congestive  or  passive  character; 
or  as  it  is  met  with  in  an  unhealth}"  constitution,  affecting  a  sj^ecific 
form. 


120 


INFLAMMATION. 


In  the  management  of  these  various  forms  of  chronic  inflammation  the 
patient  must  be  kept  at  rest,  and,  if  the  disease  be  at  all  extensive,  con¬ 
fined  to  bed.  He  should  be  in  pure  air,  and,  as  a  general  rule,  be  put  on 
a  light  and  unstimulating  diet.  The  regulation  of  the  diet  is  of  much 
consequence,  and  the  amount  and  quality  of  the  nourishment  afforded 
must  be  carefully  proportioned  to  the  age,  strength,  and  previous  habits 
of  the  patient,  as  well  as  to  the  degree  and  the  seat  of  the  inflammation, 
and  the  form  of  constitutional  fever  that  accompanies  it.  In  the  more 
acute  form  of  chronic  inflammation,  farinaceous  slops,  at  most  beef-tea, 
and  light  puddings,  can  alone  be  allowed.  In  the  less  active  forms  occur¬ 
ring  in  feeble  constitutions,  with  depression  of  general  power,  animal 
food  of  a  light  kind  may  be  given,  and  the  scale  of  nourishment  increased 
until  stimulants,  as  beer,  wine,  or  brandy,  are  allowed.  Nothing  requires 
greater  nicety  in  practice  than  to  proportion  the  diet,  and  to  determine 
the  cases  in  which  stimulants  are  necessary.  It  may  be  stated  gene¬ 
rally  that,  the  more  the  disease  assumes  the  asthenic  and  passive  forms, 
the  more  are  stimulants  required  ;  until,  at  last,  in  the  truly  adynamic 
type  our  principal  trust  is  in  these  agents,  and  large  quantities  of  wine, 
brandy,  and  ammonia  are  required  to  maintain  life. 

Mercury  is  of  essential  service  in  the  more  active  forms  of  chronic 
inflammation;  but  in  all  cachetic  and  strumous  constitutions  it  should, 
as  much  as  possible,  be  avoided.  It  is  not  only  of  great  use  in  arresting 
the  further  progress  of  the  disease,  but  especially  in  causing  the  absorp¬ 
tion  of  some  of  the  other  effusions  that  result  from  it,  and  in  removing 
some  of  the  effects  of  chronic  inflammation,  such  as  thickening,  harden¬ 
ing,  and  opacitj^  of  the  parts.  It  should  be  given  in  small  doses  for  a 
considerable  length  of  time,  until  the  gums  are  slightly  affected.  In 
man}^  cases  of  depressed  power  it  may  be  very  advantageously  con¬ 
joined  with  bark  or  sarsaparilla.  The  most  useful  preparations  are 
calomel  in  half-grain  or  grain  doses,  and  the  iodide  of  mercury  in  the 
same  quantities;  or,  if  a  gradual  and  continuous  effect  be  required,  the 
bichloride  in  doses  from  one-sixteenth  to  one-eio^hth  of  a  i^rain. 

Iodide  of  potassium  is  an  alterative  and  absorbent  of  the  greatest 
value,  especially  in  the  chronic  inflammations  of  fibrous  or  osseous  tissues, 
or  of  the  glands,  occurring  in  strumous  constitutions.  In  these  it  may 
often  be  substituted  with  great  advantage  for  mercury,  and  given  in 
those  cases  in  which  that  mineral  would  otherwise  be  administered.  In 
many  cases  it  is  of  essential  service  after  a  mercurial  course ;  some  days 
should,  however,  be  allowed  to  elapse  after  the  mercury  is  discontinued 
before  the  iodide  is  given,  otherwise  profuse  sali'v^ation  or  even  sloughing 
of  the  gums  is  apt  to  result. 

Sarsaparilla  is  a  very  valuable  remedy  if  obtained  good,  and  forms  an 
admirable  vehicle  for  the  preparations  of  mercury  or  iodine.  The  fluid 
extract  of  red  Jamaica  sarsaparilla,  carefully  prepared,  is  that  to  which 
I  give  the  preference  ;  and  when  the  inflammation  is  associated  with  want 
of  power,  its  value  is  certainly  very  great. 

Cod-liver  oil  is  of  the  very  greatest  value  in  the  various  strumous 
forms  of  chronic  inflammation  in  debilitated,  emaciated,  cachectic,  and 
strumous  subjects  ;  it  may  be  given  in  some  vehicle,  such  as  milk,  orange- 
wine  or  juice,  that  covers  its  taste.  In  some  cases  it  is  advantageously 
conjoined  with  the  iodide  of  potassium  ;  or,  where  there  is  much  want  of 
power,  and  strumous  anaemia  is  present,  with  the  preparations  of  iron. 
It  is  more  particularly  in  children  and  young  people  that  it  is  of  service 
in  removing  the  various  effects  of  chronic  inflammation. 

Purgatives  are  often  required  in  chronic  inflammation.  In  robust 


TREATMENT  OF  CHRONIC  INFLAMMATION. 


121 


subjects  in  whom  the  disease  is  active,  salines  may  be  emplojmd  ;  to 
wdiich,  if  there  be  a  rheumatic  tendency,  colchicum  may  advantageously 
be  added.  As  a  general  rule,  warm  aperients,  such  as  the  compound 
decoction  of  aloes,  with  Rochelle  salt,  answer  best ;  and  in  children  a 
powder  composed  of  one  part  of  mercury  and  chalk,  two  of  carbonate 
of  soda,  and  four  of  rhubarb,  will  be  found  very  seviceable. 

Local  Treatment  of  Chronic  Inflammation. — In  chronic  inflam¬ 
mation,  our  local  means  of  treatment  are  much  more  varied  than  in  the 
acute  form  of  the  disease. 

Local  bloodletting  is  often  required  with  a  view  of  directly  unloading 
the  vessels  of  the  part;  and  this  is  accomplished  by  scarification,  leech¬ 
ing,  or  cupping.  Scarification  is  principally  employed  in  chronic  inflam¬ 
mation  of  the  mucous  membranes.  Leeches  may  very  usefully  be 
employed,  in  some  forms  of  chronic  inflammation,  by  appl^ung  two  or 
three  at  a  time,  and  repeating  this  aj^plication  every  second  or  third  day. 

Warmth  and  moisture  are  not  so  serviceable  in  chronic  as  in  acute 
inflammation,  and  care  should  be  taken  that  they  be  not  continued  for 
so  long  a  time  as  to  sodden  the  pjarts.  An  astringent  or  stimulant,  such 
as  liquor  plumbi  or  spirits  of  wine,  may  often  advantageously  be  added 
to  the  warm  application. 

Cold  is  seldom  required  in  any  but  the  advanced  stages  of  chronic 
inflammation,  in  which  there  are  debility  and  passive  congestion  of  the 
vesseljs  of  the  part.  In  order  to  remove  this  state  of  things,  its  appli¬ 
cation  should  not  be  continuous,  but  should  be  made  twice  or  thrice  a 
day,  so  as  to  occasion  a  sudden  shock,  and  produce  a  constringent  effect 
upon  the  enfeebled  circulation  of  the  part.  This  is  best  done  by  pump¬ 
ing  or  pouring  cold  w'ater  from  a  height,  or  b}^  douching,  and  should  be 
followed  b}^  active  friction  with  the  hands. 

Friction  is  often  of  great  service  in  some  of  the  forms  of  congestive 
inflammation,  by  the  removal  of  the  thickening,  stiffening,  and  indura¬ 
tion  that  result.  Friction  may  be  practised  either  with  the  naked  hand, 
or  with  some  embrocation  of  a  stimulatinsr  or  absorbent  character. 

o 

Counterirritants  are  amongst  the  most  energetic  local  means  that  we 
possess  for  combating  chronic  inflammation.  Rubefacients,  in  the  shape 
of  stimulating  embrocations,  to  which  absorbents,  such  as  mercurial 
ointment,  may  often  advantageous!}’’  be  added,  are  usefully  employed  as 
adjuncts  to  friction. 

By  means  of  blisters,  applied  either  directly  over  the  inflamed  part,  or 
at  a  little  distance  from  it,  the  surface  being  kept  raw  and  exuding  by 
some  stimulating  application,  effusions  and  those  chronic  structural 
changes  that  accompany  the  more  advanced  stages  of  inflammation  may 
be  removed. 

In  the  latter  stages  of  chronic  inflammation,  the  pyogenic  counter- 
irritants — issues,  setons,  and  the  cautery — may  be  very  advantageously 
employed.  By  these  a  powerful  derivative  action  is  induced,  and  chronic 
thickening  may  be  melted  away. 

Issues  are  of  especial  service  in  chronic  inflammation  of  the  viscera, 
joints,  and  bones,  before  suppuration  has  taken  place.  They  should  be 
applied  in  the  soft  parts  over  the  affected  structures,  and  may  be  kept 
open  for  a  very  considerable  length  of  time.  They  are  best  made  in  the 
following  manner.  A  piece  of  common  adhesive  plaster,  about  two 
inches  square,  having  a  hole  of  the  size  of  a  shilling  cut  in  its  middle, 
is  fixed  upon  the  part  where  the  issue  is  to  be  made ;  a  piece  of  potassa 
fusa,  of  about  the  size  of  half  a  cheny-stone,  is  then  placed  on  the  sur¬ 
face  left  uncovered  by  the  circular  central  aperture,  a  square  piece  of 


122 


INFLAMMATION. 


plaster  being  laid  over  all.  The  patient  experiences  a  burning  pain  for 
about  two  hours,  when  it  ceases  ;  on  removing  the  plasters,  a  black 
slough,  corresponding  in  size  to  the  central  aperture,  will  be  found. 
This  must  be  poulticed  for  a  few  da3"s,  until  it  separates,  and  the  raw 
surface  then  dressed  with  savine  ointment,  or  stimulated  by  an  issue- 
bead.  Whenever  it  shows  a  tendenc3^  to  heal,  it  ma3’-  be  kept  open  by 
an  occasional  application  of  the  potassa  fusa. 

A  Seton^  when  counter-irritation  is  to  be  applied  over  very  deep-seated 
parts,  is  more  useful  than  an  issue.  The  seton  may  most  conveniently 
be  made  in  the  following  wa3'  ^8).  A  fold  of  skin  about  two 


Fig.  58. 


Introduction  of  a  Seton. 


inches  or  more  in  breadth  is  pinched  up,  and  its  base  transfixed  by  a 
narrow-bladed  bistouiy.  The  blunt  end  of  an  e3’ed  probe,  threaded  with 
the  seton,  is  next  pushed  along  the  back  of  the  blade  from  heel  to  point, 
which,  being  withdrawn  as  the  probe  is  carried  onwards,  the  seton  is  left 
in  the  wound.  A  poultice  should  then  be  applied. 

The  Actual  Cautery  is  especially  successful  in  deep-seated  chronic 
inflammation,  as  of  joints,  when  a  deep  and  prolonged  action  is  required 
to  be  set  up.  The  cauterizing  irons  ma3"  be  of  various  shapes.  They 
should  be  heated  to  a  dull  red  heat,  and  then  quickl3'  drawn  in  lines, 
crossing  one  another  over  the  part. 

Astringents  directly  applied  to  the  inflamed  parts  are  of  extreme  ser¬ 
vice  in  those  forms  of  congestive  or  passive  inflammation  in  which  the 
circulation  is  sluggish  and  the  capillaries  loaded ;  the3^  afford  relief  in 
these  cases  ly  inducing  contraction  of  the  vessels.  In  order  to  ensure 
their  proper  action,  the3^  must  be  emplo3"ed  of  sufficient  strength  ;  for  if 
too  weak  they  irritate,  and  increase  rather  than  relieve  the  congested 
condition.  The  nitrate  of  silver  is  the  astringent  that  is  commonl3^  pre¬ 
ferred  ;  and  this,  applied  either  solid,  or  in  solution  containing  from  ten 
grains  to  one  drachm  of  the  salt  in  one  ounce  of  distilled  water,  will 
produce  a  veiy  marked  beneficial  influence  in  congestive  inflammation  of 
the  mucous  and  cutaneous  surfaces. 

Pressure  b3'  means  of  well-applied  bandages,  elastic  "webbing,  or 
strapping,  is  of  essential  service  iu  supporting  the  feeble  vessels  in  con¬ 
gestive  inflammations.  In  many  cases  pressure  may  be  advantageously 
conjoined  with  absorbents  and  rubefacients,  as  mercurial  and  camphor 
liniments,  or  the  plaster  of  mercuiy  and  ammoniacum.  This  treatment,^ 
ly  removing  congestion,  and  promoting  the  absorption  of  inflammatory 
eflTusion,  is  especially  useful  in  chronic  forms  of  inflammation  accom¬ 
panied  b3"  thickening  of  parts,  as  in  the  joints  and  testes. 


CHARACTERS  OF  PUS. 


123 


CHAPTER  V. 


SUPPURATION  AND  ABSCESS. 


Suppuration,  or  the  formation  of  pus,  has  alreaclj^  been  referred  to 
in  the  last  chapter,  as  one  of  the  results  of  inflammation.  It  consists, 
in  fact,  as  will  be  presentl}^  described,  of  a  continuance  and  exaggeration 
of  one  of  the  factors  of  inflammation — the  excessive  formation  of  white 
cells. 

Characters  of  Pus. — Pus  presents  considerable  variety  in  its  gene¬ 
ral  character,  according  to  the  nature  of  tlie  constitution  of  the  patient, 
or  the  condition  of  the  part  in  which  it  is  formed. 

When  formed  in  a  person  of  healthy  constitution,  as  the  result  of 
sthenic  inflammation,  it  is  an  opaque,  creamy  fluid,  thick,  smooth,  and 
slightly  glutinous  to  the  touch ;  of  a  yellowish-white  color,  with  a 
greenish  tinge,  having  a  faint  odor,  and  an  alkaline  reaction.  Chemi- 
call}-,  it  contains  various  albuminous  compounds,  with  fatty  matters, 
and  salts,  chiefly  chloride  of  sodium:  it  usually  gives  off  a  small  quan¬ 
tity  of  ammonia.  Pus  presenting  these  characters  is  termed  healthy  or 
laudable. 

When  admixed  and  tinged  with  blood,  pus  is  said  to  be  sanious ;  when 
thin,  watery,  and  acrid,  ichorous ;  when  containing  cheesy-looking  flakes, 
it  is  termed  curdy ;  and  when  diluted  with  mucous  or  serum,  it  is  fre¬ 
quently  called  muco-pusj  or  sero-pus.  Besides  these,  pus  presents  many 
other  varieties.  Thus,  for  instance,  when  formed  from  bone,  or  in  the 
neighborhood  of  the  alimentary  canal,  it  has  a  peculiar  fetid  odor.  Its 
chemical  composition  may  likewise  vaiy  under  different  circumstances  : 
thus,  ordinary  pus  formed  in  the  soft  parts  contains  merel}'  a  trace  of 
phosphate  of  lime,  whereas  that  which  is  formed  in  connection  with 
diseased  bone  has  been  found  by  B.  Cooper  to  contain  per  cent,  of 
this  salt.  Pus  presents  other  peculiarities,  w’hich  are  only  cognizable  by 
their  effects  on  the  S3'stem :  thus,  the  pus  from  specific  sores  possesses 
contagious  properties,  though  in  chemical,  microscopical,  and  physical 
constitution,  it  does  not  differ  from  other  forms  of  that  fluid. 

Microscopic  Characters. — On  examining  pus  under  the  microscope,  it 
is  found  to  consist  of  corpuscles  floating  in  a  homogeneous  fluid,  the 
‘‘liquor  puris.”  These  corpuscles  are  composed  of  a  semi-transparent 
cell  wall,  containing  two  or  three  nuclei,  which  are  rendered  very  appa¬ 
rent  by  acetic  acid  (Fig.  59).  The 

appearance  here  described,  how-  Fig-  59. 

ever,  is  that  of  the  corpuscles  in 
the  dead  state,  after  removal  from 
the  body,  and  when  their  tempe¬ 
rature  has  fallen.  The  researches 
of  Von  Recklinghausen,  Schultze, 
and  others  have  shown  that  these 
corpuscles  (and  the  w^hite  corpus¬ 
cles  of  the  blood)  undergo  changes  of  form  like  those  of  the  amoeba. 
When  examined  under  favorable  circumstances,  they  seem  to  shoot  out 


a.  Healthy  Pas-cells,  b.  Treated  with  Acetic  Acid. 
Magnified  800  Diameters. 


124 


SUPPURATION  AND  ABSCESS. 


projections,  and  to  withdraw  them  ;  and  it  has  also  been  found  that,  like 
the  amoeba,  the}^  have  the  power  of  incorporating  into  their  substance, 
matters,  such  as  pigments,  with  which  they  come  into  contact.  Besides 
these  corpuscles,  granular  matter,  particles  of  fibrine,  and  disintegrated 
cells,  are  usuall}’’  found  admixed  in  greater  or  less  amount.  The  greater 
the  quantity  of  corpuscles,  the  richer  and  more  creamj^  is  the  pus. 

In  many  cases,  however,  the  microscopical  characters  of  pus  differ 
from  those  that  have  just  been  given.  Thus  in  the  thin,  greas}^,  yellow*- 
ish-looking  pus,  somewhat  resembling  melted  butter,  which  we  find  in 
the  joints  in  pysemia,  the  pus-corpuscles  are  irregular  in  outline,  and  not 
so  distinctly  nucleated  (Fig.  60);  and  in  some  forms  of  chronic  abscess. 


Fig.  60.  Fig.  61. 


Pus-cells  from  Pyaemic  Abscess.  Pus  cells  from  Scrofulous  Abscess. 


when  the  pus  is  thin  and  curdy,  the  pus-corpuscles  present  a  somewhat 
similar  appearance,  undergoing  fatty  degeneration  (Fig.  61). 

Diagnosis. — The  diagnosis  of  pus  is  usually  eas}^,  but  some  fluids 
resemble  pus  so  closely  to  the  naked  eye,  that  the  microscope  is  necessary 
to  establish  their  characters.  From  healthy  mucus  there  is  no  difficulty 
in  distinguishing  pus  ;  but  when  mucus  has  been  thickened  and  rendered 
opaque  by  inflammation,  and  is  mixed  with  exudation-cells,  it  is  impos¬ 
sible,  and  can  never  be  necessary  to  distinguish  it  from  pus.  Turhid 
Serum.^  containing  broken-down  and  granular  fibrine,  frequently  met  with 
in  serous  sacs,  and  softened  fibrine^  as  in  clots  and  inflamed  vessels,  are 
distinguished  from  pus  by  the  absence  of  pus-cells.  Atheroma  is  recog¬ 
nized  by  the  presence  of  cholesterine-scales  and  fat,  and  by  the  non¬ 
existence  of  the  characteristic  pus-corpuscles.  In  tubercle  and  cancer 
the  absence  of  the  true  pus-cell,  and  the  presence  of  appearances  char¬ 
acteristic  of  these  morbid  products,  establish  the  diagnosis.  When  it  is 
admixed  with  bloody  the  detection  of  pus  is  often  very  difficult,  and, 
indeed,  cannot  in  many  cases  be  satisfactorily  accomplished,  on  account 
of  the  close  resemblance  between  the  white  corpuscles  and  its  cells. 
When  pus  is  diffused  in  milk^  as  in  some  forms  of  lacteal  abscess,  the 
corpuscles  of  this  fluid  will  be  seen  to  be  smaller  and  clearer,  with  a 
more  defined  outline  than  those  of  pus. 

Pyogenesis,  or  the  Formation  of  Pus,  is  an  interesting  study. 
The  older  Surgeons  believed  that  this  fluid  w^as  formed  b}^  the  breaking 
up  or  disintegration  of  the  solid  tissues,  or  that  it  was  the  result  of  their 
liquefaction  or  saponification  by  the  acid  products  of  inflammation. 
Quesnay  and  Haller  exposed  the  fallacy  of  these  opinions  ;  and  modern 
pathologists  look  upon  pus  as  a  direct  product  of  inflammation.  When 
suppuration  takes  place,  there  is  indeed  a  breaking  up  of  the  tissues ; 
but  it  is  not  their  mere  debris  wffiich  constitutes  pus. 

The  close  resemblance  between  the  white  blood-corpuscles  and  those 


PATHOLOGY  OF  SUPPURATION. 


125 


of  pus  was  pointed  out  as  long  ago  as  1846,  by  Drs.  W.  Addison  and  A. 
Waller,  but  their  observations  seem  to  have  been  almost  forgotten  until 
about  four  ^^ears  ago,  since  which  time  an  interesting  investigation  has 
been  carried  on  by  several  observers,  as  to  the  source  of  the  pus-corpuscles, 
and  the  manner  in  which  their  numbers  become  increased.  The  researches 
on  this  point  have  an  intimate  connection  with  those  to  which  reference 
was  made  in  the  previous  chapter,  on  the  behavior  of  the  white  corpus¬ 
cles  of  the  blood  in  inflammation. 

The  mode  of  formation  of  pus  has  been  examined  by  Cohnheim, 
Hoffmann,  and  Yon  Kecklinghausen,  in  the  cornea  of  the  frog — a  non- 
vascular  tissue.  On  injuring  the  cornea,  there  follows  in  two  or  three 
days  a  yellowish  opacity^,  due  to  pus-corpuscles,  and  commencing  always, 
according  to  Colinheim,  at  the  periphery,  even  when  the  lesion  is  central. 
The  pus,  it  is  hence  inferred,  cannot  have  been  formed  in  the  cornea,  but 
must  have  come  from  without ;  but  from  what  source?  It  had  been  shown 
that  finely  divided  coloring  matter,  when  brought  into  contact  with  cells, 
such  as  those  of  pus,  is  taken  up  and  retained  b}^  them.  Accordingly 
Cohnheim  introduced  aniline  blue,  and  Hoffman  and  Ton  Recklinghausen 
cinnabar,  into  the  blood  ;  and,  on  afterwards  examining  the  pus,  found 
it  colored  by  these  substances,  wliich  had  been  taken  up  by  its  corpus¬ 
cles.  On  introdiicino-  the  same  substances  into  the  anterior  chamber  of 

o 

the  eye,  and  the  injured  cornea,  no  such  effect  was  produced.  Hence  the 
inference  was,  that  at  least  many  of  the  pus-cells  come  from  the  blood. 

It  is  still  a  debated  question,  whether  all,  or  even  the  majorit}^,  of  the 
pus-coiq^uscles  are  to  be  accounted  for  by  migration  through  the  walls 
of  the  blood-vessels.  That  this  is  the  source  of  most  of  them,  was  the 
view  held  by  Cohnheim,  who  regarded  the  blood-forming  organs — the 
spleen  and  l^’mphatic  glands — as  their  ultimate  source.  Others,  how¬ 
ever,  including  Billroth,  Hoffmann,  and  Yon  Recklinghausen,  consider 
that  a  large  proportion  of  the  pus-cells  must  be  formed  in  the  tissues 
outside  the  vessels,  especially'  in  the  corpuscles  of  the  connective  tissue. 
This  view  is  that  which  appears  to  be  most  generally  received.  Burdon 
Sanderson  remarks  that  “  in  every  limited  inflammation  of  the  subcuta¬ 
neous  tissue,  and  in  the  neighborhood  of  every  subcutaneous  abscess,  a 
region  is  found  outside  of  the  focus  of  suppuration,  in  which  the  connec¬ 
tive  tissue  corpuscles  present  alterations  w'hich  are  so  distinct,  that  it 
is  impossible  for  any  one  who  is  conversant  with  them  to  doubt  that 
they  signify  that  the  issue  is  germinating.” 

Relation  of  Suppuration  to  other  Changes  in  the  Tissues. — 
The  essential  characteristic  of  suppuration  is,  as  has  been  showm,  the 
development  in  excessive  number  of  corpuscles  closely^  resembling,  if 
not  indeed  identical  with  the  colorless  corpuscles  of  the  blood.  It  is 
dependent  on  inflammation,  although  in  some  cases,  such  as  the  “cold 
abscess”  to  be  hereafter  described,  the  other  phenomena  of  inflammation 
may’’  be  veiy  slightly^  marked ;  and  it  therefore  is  found  to  occur  along 
with  the  other  tissue-changes,  wdiether  of  repair  or  of  destruction,  w'hich 
are  connected  with  inflammation. 

The  process  of  repair  of  injuries,  as  will  be  described  hereafter,  is 
attended  in  general  by'  more  or  less  of  inflammation,  under  which  a  sup¬ 
ply^  of  organizable  fibrinous  matter  or  ly'mph  is  throw’n  out,  and  under¬ 
goes  conversion  into  cicatricial  tissue.  Y ery-  frequently' — especially  under 
exposure  to  the  air — suppuration  takes  place  at  the  same  time.  In  an 
ordinarily  healthy  subject,  this  plastic  or  adhesive  inflammation  gradu¬ 
ally'  gains  ground,  and  overcoming  the  tendency  to  suppuration,  closes 
the  wound.  In  such  cases  the  pus,  so  long  as  it  is  formed,  is  of  the 


126 


SUPPURATION  AND  ABSCESS. 


“  health}^”  or  “  laudable”  kind.  And  though  the  suppuration  is  by  no 
means  essential  to  the  process  of  repair,  still  the  presence  of  pus  of  this 
kind  indicates  a  healthy  condition  of  the  system  and  of  the  part. 

In  other  cases,  especially  in  cachetic  or  specificall}"  diseased  states  of 
the  s3'stem,  the  material  effused  from  the  bloodvessels  is  deficient  in 
plastic  propert}^,  neither  repairing  the  wound  nor  forming  “  laudable” 
pus ;  but  consisting  of  a  thin  serous  fluid  containing  corpuscles.  This 
will  be  again  referred  to  in  Chapter  YII.,  in  describing  the  process  of 
“  Union  by  Adhesive  Inflammation.” 

Circumstances  Influencing  the  Tendency  to  Suppuration. — 
Why  do  the  adhesive  or  fibrinous  products  of  inflammation  preponderate 
in  some  cases,  and  the  suppurative  or  corpuscular  in  others  ?  This  ques¬ 
tion  has  been  closely  investigated  by  Hunter,  Bichat,  Rokitansky,  and 
C.  J.  B.  Williams,  and  has  been  veiy  clearl}^  replied  to  by  Sir  James 
Paget,  wdio  has  pointed  out  that  the  difference  is  dependent  on  three 
causes : — 1.  The  state  of  the  blood  ;  2.  The  seat  of  the  inflammation  ; 
3.  The  degree  and  character  of  the  inflammation. 

1.  State  of  the  Blood. — Paget  applied  blisters  to  thirty  different  pa¬ 
tients,  and  collected  the  sero-fibrinous  fluid  that  accumulated  in  the 
blebs.  In  those  who  were  suffering  from  purely  local  diseases,  the  con¬ 
stitution  being  otherwise  health}^,  the  fluid  was  firm,  filamentous,  and 
elastic  ;  in  cachetic  or  phthisical  patients  it  was  almost  wholly  corpuscu¬ 
lar;  with  every  intermediate  variety,  according  to  the  condition  of  the 
sj’stem.  As  a  general  rule,  in  young  persons,  and  in  tliose  of  sound 
constitution,  the  fibrine  is  plastic;  hence  it  is  in  these  individuals  that 
w'e  may  chief!}'  look  for  the  union  of  wounds  by  adhesive  inflammation. 
In  scrofulous  constitutions,  on  the  other  hand,  the  inflammation  that  is 
excited  by  a  trivial  injury,  as  the  sprain  of  a  joint  for  instance,  is  very 
apt  to  run  to  suppuration.  So  again,  in  certain  cachectic  states  of  the 
system,  slight  wounds  suppurate,  or  fester  as  it  is  termed. 

2.  The  Seat  of  inflammation  modifies  its  product  very  considerabl}', 
as  Bichat  and  Hunter  long  ago  pointed  out.  Serous  membranes  are 
prone  to  fibrinous,  the  mucous  to  suppurative  inflammation;  and  in 
areolar  tissue,  both  fibrine  and  corpuscles  are  found.  This  general  rule, 
however,  is  subservient  to  the  state  of  the  constitution,  and  to  the 
influence  of  certain  specific  diseases.  Thus  in  diphtherite  and  croiqD, 
lymph  is  poured  out  on  the  mucous  membrane  of  the  throat;  whilst,  in 
empyema,  pus  is  formed  in  the  cavity  of  the  pleura. 

3.  The  Degree  and  Character  of  the  inflammation  modify  considerably 
the  product.  When  the  inflammation  is  of  an  active  sthenic  character  in 
a  healthy  constitution,  it  requires  considerable  intensity  to  give  rise  to 
suppuration.  It  is  only  where  the  system  is  strongly  predisposed  by 
struma  or  cachexy,  that  very  slight  inflammations  terminate  in  this 
way.  The  degree  of  inflammation  required  for  the  formation  of  pus 
varies  greatly,  but  it  is  always  greater  than  that  necessary  for  plastic 
exudation.  Certain  forms  of  inflammation  are  alwa3's  attended  by 
specific  products.  In  pyaemia,  for  instance,  all  the  products  have  a  sup¬ 
purative  tendency,  even  when  serous  membranes  are  inflamed.  In  croup, 
on  the  other  hand,  there  is  a  disposition  to  plastic  effusion  even  on 
mucous  surfaces.  The  specific  character  of  the  inflammation  often 
determines  the  supervention  of  suppuration:  some  diseases,  such  as 
gonorrhoea  and  purulent  ophthalmia,  consisting  essentially  in  the  secre¬ 
tion  of  pus  by  a  free  surface. 

4.  In  addition  to  the  conditions  above-mentioned,  the  Local  condition 
of  the  Paid  influences  the  probability  of  suppuration.  Thus  a  subcuta- 


SYMPTOMS  OF  SUPPURATION. 


127 


neons  wound,  as  in  tenotom}',  does  not  suppurate ;  but  if  it  be  opened, 
and  its  interior  exposed  to  the  air,  then  suppuration  takes  place.  For 
the  same  reason  all  ulcers  suppurate.  The  lodgment  of  foreign  bodies, 
as  of  urine,  a  piece  of  bone,  or  a  bullet,  by  exciting  intense  and  continu¬ 
ous  inflammation,  almost  inevitably  leads  to  suppuration,  which  is 
indeed  the  means  adopted  by  nature  for  their  removal  from  the  system. 

The  Duration  of  suppuration  varies  greatl}’.  Inflammation  very 
commonly  terminates  in  the  formation  of  pus,  in  the  course  of  about 
three  days;  at  other  times  a  much  longer  period  than  this  is  required, 
the  inflammatoiy  action  being  passive  and  languid.  When  once  suppu¬ 
ration  has  been  set  up,  it  ma^^  continue  for  an  indefinite  time;  the 
formation  of  pus-cells  becoming,  as  it  were,  the  established  condition 
of  the  part.  It  is  not  uncommon  to  find  purulent  discharges  from  mu¬ 
cous  membranes  continuing  for  years. 

Symptoms  of  Suppuration  — These  are  local  and  constitutional. 

The  Local  Symptoms  differ  as  the  suppuration  occurs  on  a  mucous 
surface,  or  in  the  interior  of  a  tissue  or  organ. 

When  an  inflamed  mucous  surface  is  about  to  suppurate,  the  membrane 
presents  the  ordinary  characters  of  active  inflammation,  being  swollen, 
red,  and  often  painful ;  to  these  a  discharge  is  speedily  superadded. 

When  suppuration  is  about  to  take  place  in  the  substance  of  tissues 
or  organs,  constituting  an  abscess  in  one  of  the  forms  to  be  presently 
described,  the  local  s3’mptoms  of  inflammation  undergo  certain  modifi¬ 
cations  indicative  of  the  supervention  of  this  action.  The  pain  becomes 
throbbing ;  the  part  swells  and  becomes  tense,  but  after  a  time  softens ; 
and  fluctuation  or  undulation  ma^'  be  detected  in  it.  The  skin  becomes 
glazed,  red,  shining,  and  oedematoiis.  In  other  cases,  again,  suppura¬ 
tion  occurs  without  aiy  evident  sign  of  local  inflammation,  the  presence 
of  the  pus  revealing  itself  by  swelling  and  fluctuation  onl^*. 

Constitutional  Symptoms. — On  the  supervention  of  extensive  suppu¬ 
ration  the  ordinar}"  S3’mptoms  of  inflammation  subside,  and  are  usuall3" 
interrupted  b3'  the  occurrence  of  chills,  alternation  of  heat  and  cold ; 
or,  if  the  formation  of  pus  be  extensive,  b3^  severe  and  long-continued 
rigors.  The  fever  often  assumes  a  somewhat  intermittent  character, 
and  its  intensit3’  lessens,  the  pulse  becoming  soft,  though  continuing 
quick.  If  pus  be  formed  in  sufficient  quantity’  for  its  discharge  to  act 
as  a  severe  drain  on  the  constitution,  other  symptoms  speedil3’  set  in, 
dependent  on  the  loss  that  is  going  on.  The  patient  becomes  weak,  his 
nutrition  is  impaired,  and  hectic  is  established. 

Hectic  does  not  come  on  unless  there  be  a  discharge  of  pus  from  the 
S3’stem.  Xo  hectic  occurs  so  long  as  an  abscess,  however  large,  con¬ 
tinues  unopened ;  but  it  supervenes  with  great  rapidit3"  when  once  its 
contents  are  discharged.  I  have  known  a  large  abscess  to  exist  un- 
opened  for  two  3’ears,  without  an3’ constitutional  disturbance;  but,  so 
soon  as  it  was  opened,  well-marked  hectic  set  in,  which  speedil3’  carried 
off  the  patient. 

Hectic  is  essentially  a  fever  of  debilit3’,  conjoined  with  irritation. 
Emaciation  and  general  loss  of  power  invariabh’  accompany  it.  The 
pulse,  which  is  quick,  small,  and  compressible,  rises  from  ten  to  twenty 
beats  above  its  normal  standard  ;  the  tongue  becomes  red  at  the  edges 
and  tip ;  the  cheeks  are  often  flushed,  and  the  e3’es  glistening,  with 
dilated  pupils ;  all  these  s3'mptoms  have  a  tendency  to  exacerbation 
after  meals  and  towards  evening.  There  is  also  increased  action  either 
of  the  skin,  bowels,  or  kidne3'S.  Thus,  profuse  sweating,  copious 
purging,  and  abundant  red  deposits  in  the  urine  take  place  ;  these  dis- 


128 


SUPPURATION  AND  ABSCESS. 


charges  often  alternate  with  one  another,  as  it  were,  melting  the  patient 
away,  and  hence  are  termed  colliquative.  The  debility  gradually 
increasing,  the  patient  rapidly  wastes,  and  at  last  dies  from  sheer 
exhaustion,  the  conjoined  result  of  fever,  malnutrition,  and  wasting 
discharges. 

In  some  cases  of  extensive  suppuration,  especially  in  children,  hectic 
does  not  occur,  but  marasmus  or  atrophy  takes  place  instead,  the  child 
wasting  away  without  fever,  and  being  carried  off  at  last  by  exhaustion 
or  some  intercurrent  disease. 

Forms  in  which  Suppuration  occurs. — Suppuration  may  occur 
on  the  mucous  or  serous  surfaces,  or  on  the  surfaces  of  ulcers  or 
w'ounds,  constituting  Purulent  Secretion  or  Exudation;  or  pus  may  be 
collected  in  the  interior  of  a  tissue  or  organ,  forming  an  Abscess. 

Abscess. — An  Abscess  signifies  a  collection  of  pus  occurring  in  any 
of  the  tissues  or  organs  of  the  bod}'.  In  structure,  an  abscess  consists 
of  an  accumulation  of  pus  situated  in  the  midst  of,  and  surrounded  on 
all  sides  by,  a  layer  of  fibrine  deposited  in  and  consolidating  the  neigh¬ 
boring  tissues.  This  lymph,  which  constitutes  the  wall  of  the  abscess, 
varies  greatly  in  thickness  and  consistence  ;  in  some  cases  being  scarcely 
perceptible,  in  others  some  lines  in  thickness  and  of  corresponding  firm¬ 
ness,  constituting  perhaps  the  principal  part  of  the  mass.  This  wall  of 
“  limiting  fibrine”  is  always  very  vascular,  in  consequence  of  the  inflam¬ 
mation  and  congestion  of  the  tissues  that  enter  into  its  composition. 
Surgeons  divide  abscesses  into  various  kinds,  according  to  the  symptoms 
attending  them,  their  duration,  and  their  cause.  Thus  they  speak  hab¬ 
itually  of  Acute  and  Chronic,  Hot  and  Cold,  Lymphatic,  Diffuse,  Meta¬ 
static,  and  Puerperal  Abscesses. 

Acute  or  Phlegmonous  Abscess  may  be  taken  as  the  type  of  the  dis¬ 
ease.  When  it  is  about  to  form,  the  part  which  has  been  previously 
inflamed  swells  considerably,  with  a  throbbing  pulsatile  pain  ;  the  skin 
becomes  shining,  glazed,  and  of  a  somewhat  purplish  red.  If  the 
abscess  be  very  deeply  seated,  the  superimposed  tissues  become  brawny 
and  oedematous,  without,  perhaps,  any  other  sign  indicating  the  exist¬ 
ence  of  pus.  As  the  swelling  approaches  the  surface,  it  softens  at  one 
part,  where  fluctuation  becomes  perceptible,  and  a  bulging  of  the  skin 
covering  its  summit  takes  place  ;  this  pointing  of  the  abscess  indicates 
that  it  is  about  to  burst  and  discharge  its  contents,  which  it  speedily  will 
through  a  circular  aperture  formed  in  the  skin. 

The  intimate  pathological  phenomena  attending  the  formation  of  an 
abscess  are  as  follows.  In  the  inflamed  part  a  collection  of  white  cells 
takes  place  in  the  areolar  tissue  and  gradually  increases ;  meanwhile, 
the  proper  tissue  of  the  part  is  broken  down  and  removed,  or  its  shreds 
may  remain  mixed  with  the  pus.  The  tissue  lying  beyond  this  collection 
of  pus  is  very  vascular,  and  is  inflltrated  with  new  plastic  matter,  which, 
in  healthy  states  of  the  system,  forms  a  layer  of  “limiting  fibrine”  or 
“limiting  membrane.” 

An  abscess,  perhaps  originally  deeply  formed  in  the  substance  of  a 
limb,  increases  by  the  additions  of  cells  from  the  bloodvessels  of  the 
limiting  membrane,  and  also  probably  from  the  acting  of  the  already 
effused  amoeboid  cells  on  the  tissues  with  which  they  come  in  contact. 
As  the  abscess  extends,  it  has  a  special  tendency  to  approach  a  free 
surface,  whether  that  be  external  or  internal,  skin  or  mucous  membrane  ; 
the  tissues  between  it  and  the  surface  towards  which  it  is  progressing 
being  gradually  broken  down,  at  the  same  time  that  the  formation  of 
cells  is  increased  by  the  continuance  of  the  inflammatory  process  in  this 


s^aeieties  of  abscess. 


129 


direction.  It  is  in  this  that  the  pointing  essentially^  consists.  As  the 
abscess  approaches  the  surface,  the  skin  at  first  becomes  more  or  less 
livid,  tense,  and  oedematous,  indicating  the  interference  with  its  circula¬ 
tion  ;  as  the  summit  of  the  abscess  presses  upwards,  the  overlying  skin 
loses  its  tension  and  becomes  relaxed  ;  it  then  sloughs  at  the  most  cen¬ 
tral  point,  from  which  the  cuticle  has  previously  peeled  off,  and,  the 
outward  pressure  of  the  pus  speedily  detaching  the  slough,  the  abscess 
discharges  itself.  Though  acute  abscesses,  if  left  to  themselves,  usually 
run  this  course  and  burst  through  the  skin,  the  mucous  or  serous  sur¬ 
faces,  or  even  into  the  interior  of  joints,  yet  some  collections  of  pus,  if 
very  deeply  seated,  cannot  find  their  way  to  the  surface,  but  extend 
through  the  areolar  planes  of  the  limb  in  a  lateral  direction,  burrowing 
and  undermining  the  parts  to  a  great  extent ;  or,  if  situated  in  dense 
and  unyielding  structures,  as  in  bone,  are  imprisoned  within  a  case 
through  which  they  may  be  unable  to  penetrate  ;  in  other  rare  instances, 
the  pus  becomes  absorbed,  and  the  abscess  disappears.  After  an  abscess 
has  burst  or  has  been  eradicated,  its  walls,  which  have  a  close  resem¬ 
blance  to  a  granulating  surface,  usually  unite  and  close  the  cavity’’ ;  in 
some  cases,  however,  the  cavity  does  not  completely  close,  but  contracts 
into  a  narrow  canal,  forming  a  sinus  or  fistula  (p.  140). 

Diffuse  Abscess  forms  rapidly  in  the  areolar  tissue,  as  the  result  of 
diffuse  inflammation.  There  is  no  limiting  fibrine,  and  hence  the  pus 
often  spreads  widely",  producing  extensive  destruction  of  parts  before 
it  is  discovered.  A  particular  variety"  of  this  form  of  abscess  is  the 
Puerperal^  occurring  in  women  after  parturition,  in  various  parts  of  the 
body",  especially  in  the  iliac  fossa,  in  the  areolar  planes  of  the  thigh  or  in 
the  joints,  and  in  the  adipose  tissue  of  the  orbit,  often  destroy"ing  the 
globe  of  the  eye.  To  these  forms  of  the  disease  the  Metastatic  Abscesses 
are  closely  allied.  They  commonly"  occur  in  connection  with  phlebitis 
and  pyaemia,  are  very"  numerous,  and  are  met  with  in  the  substance  of 
organs  as  well  as  in  the  areolar  tissue  and  joints.  The  last  three  species 
of  abscess  are  varieties  of  acute  form. 

Chronic  Abscesses  are  of  very  common  occurrence.  The  tissue  in  the 
vicinity  of  a  piece  of  dead  bone  being  irritated  by  its  presence,  or  a  gland 
or  some  portion  of  the  subcutaneous  areolar  tissue  having  become  indu¬ 
rated,  tender,  or  subacutely  inflamed,  at  last  slowly  and  without  any 
constitutional  symptoms,  or  much  appearance  of  local  disturbance  except 
the  swelling,  softens  and  breaks  down  into  a  somewhat  thin,  flaky,  curdy 
puriform  fluid,  though  in  other  instances  the  pus  is  perfectly  healthy. 
These  abscesses  do  not  readily"  point,  but  often  extend  laterally,  burrow¬ 
ing  for  a  considerable  distance  from  the  original  seat.  In  other  cases 
they  become  circumscribed  by  a  thick  and  dense  wall  of  fibrine,  through 
which  it  may  be  extremely  difficult,  and  perhaps  impossible,  to  detect 
fluctuation  ;  the  disease  then  simulating  a  solid  tumor.  The  duration 
of  these  chronic  abscesses  without  opening  is  often  very  remarkable, 
even  when  situated  in  soft  parts.  I  have  seen  large  chronic  abscesses, 
in  the  iliac  fossa  and  groin,  perfectly  stationary  for  nearly  two  years. 
When  situated  in  denser  structures,  as  in  the  substance  of  the  breast, 
the  wall  may  become  so  dense  as  to  resemble  a  cy"st,  and  the  disease  will 
continue  in  the  same  state  for  a  great  length  of  time.  In  the  bones, 
abscesses  may  exist  for  an  indefinite  period. 

Cold,  Lymphatic  or  Congestive  Abscess  often  occurs  with  but  slight 
precursory  local  symptoms,  or  even  without  any  at  all.  The  patient, 
who  has  usually" been  cachectic, and  has  suffered  sometime  from  general 
debility,  feels  slight  uneasiness  in  the  groin,  iliac  fossa,  or  axilla,  and 
VOL.  I _ 9 


130 


SUPPURATION  AND  ABSCfiSS. 


Fig.  62. 


finds  suddenly  a  large  fluctuating  tumor  in  one  of  these  situations  ; 
there  is  perhaps  no  pain  in  the  part,  and  no  discoloration  of  the  skin,  but 
the  fluctuation  is  alwaj’s  very  distinct,  the  limiting  fibrine  being  in  small 
quantit}^  On  opening  such  an  abscess  as  this,  there  will  usuallj^  be  a 
copious  discharge  of  thin  unhealthy  pus,  which,  when  examined  under 
the  microscope,  will  be  found  to  contain  ill-developed,  withered  cells ;  in 
some  cases,  the  contents  appear  to  be  a  clear  semi-transparent  or  oily- 
looking  matter,  probably  sero-plastic  effusion. 

Tympanitic  or  Emphysematous  Abscess,  which  contains  gas  as  well  as 
pus,  is  occasionally  met  with  in  the  neighborhood  of  the  mucous  canals, 
chiefly  at  the  anterior  and  lateral  parts  of  the  abdominal  walls,  and 
about  the  sacrum.  Sometimes  the  communication  with  the  intestine  is 
veiy  free ;  in  other  cases  it  is  not  so  evident.  These  collections  are 
often  perfectly  resonant  on  percussion,  the  air  being  above,  the  fluid 
below;  and  sometimes  gurgling  is  very  distinct  in  them. 

Situation,  Size,  etc. — Abscesses  are  met  wdth  in  all  regions  of  the 
body,  but  more  especially  where  the  areolar  tissue  is  abundant,  and  the 

absorbent  glands  are  numerous.  They 
may  occur  at  any  period  of  life,  from 
the  earliest  infancy  to  old  age.  I  have 
opened  a  very  large  abscess  in  the  axilla 
of  a  child  about  a  fortnight  old.  Their 
size  varies  from  that  of  a  pin’s  point  to 
a  tumor  containing  a  pint  or  more  of 
pus.  In  some  cases,  when  very  large, 
they  are  multilocular,  the  different  cysts 
being  connected  by  narrow  channels  of 
communication;  in  this  way  I  have  seen 
a  large  abscess  extending  from  the  lum¬ 
bar  vertebrae  throuoh  the  iliac  fossa 

o 

down  the  thigh,  the  ham,  and  the  leg, 
until  at  last  it  was  opened  by  the  side 
of  the  tendo  Achillis,  forming  five  or 
six  distinct  cysts,  communicating  with 
one  another  by  contracted  channels 
(Fig.  62). 

Effects. — The  pressure-effects  of  an 
abscess  are  often  important  By  pres¬ 
sure  on  the  nerves  of  a  part,  it  may  give 
rise  to  very  severe  pain  and  spasm  at 
a  distance  from  its  seat.  The  pains 
occasioned  bj'^  the  pressure  of  some 
forms  of  chronic  abscess  upon  neigh- 
borino;  nerves  have  been  mistaken  for 
those  of  rheumatism  or  neuralgia. 
When  bloodvessels  come  into  relation 
with  an  abscess,  they  usually  become 
coated  by  a  thick  layer  of  lymph,  wdiich 
guards  them  from  injury.  In  some 
cases,  however,  they  are  obliterated  by 
the  conjoined  effects  of  the  pressure  and 
the  inflammation,  in  which  they  as  well 
as  the  adjacent  tissues  partake.  In 
other  cases,  more  particular!}’’ in  strumous  and  cachectic  individuals,  the 
bloodvessels,  not  having  been  guarded  by  the  protecting  lymph,  have 


Large  Lumbar  Abscess  extending  down  the 
Thigh  and  Leg. 


DIAGNOSIS  OF  ABSCESS. 


131 


ulcerated  and  burst  into  the  C3^st  of  the  abscess,  occasioning  sudden  and 
dangerous  or  even  fatal  hemorrhage.  It  is  seldom,  however  that  a  large 
artery  or  vein  pours  its  contents  into  an  abscess  that  has  not  been  opened. 
These  occurrences  have  chiefl}^  taken  place  in  the  neck,  in  which  situation 
both  the  carotid  arteiy,  as  in  a  case  described  by  Liston,  and  the  internal 
jugular  vein,  have  opened  into  the  C}^st  of  an  abscess.  The  various 
mucous  canals,  especially  the  trachea  and  the  urethra,  may  be  injuriously 
compressed  b}’  neighboring  abscesses ;  so  also  bones  may  become 
necrosed,  and  joints  inflamed  and  destro^^ed,  from  the  same  cause. 

Diagnosis. — The  diagnosis  of  abscess,  though  usuall}’  easily  made,  at 
times  requires  attention.  The  Surgeon  believes  that  an  acute  abscess  is 
about  to  form  when,  after  rigors  and  some  modiflcation  of  the  inflam- 
matory  fever,  he  finds  the  local  signs  characteristic  of  the  formation  of 
pus  ;  more  especially  a  throbbing  pain  in  the  part,  with  softening  of  any 
induration  that  ma}’’  have  existed,  and  oedema  of  the  areolar  tissue 
covering  it.  His  suspicion  is  turned  into  certaint}^,  and  he  knows  that 
an  abscess  has  formed,  when,  after  the  occurrence  of  these  sj’mptoms, 
fluctuation  can  be  felt,  and  the  other  signs  manifest  themselves.  The 
fluctuation  ma}’’,  however,  readily  be  confounded  with  the  undulatory 
sensation  communicated  b}"  some  tissues  from  the  mere  infiltration  of 
sero-plastic  fluid  into  them,  or  even  without  this,  from  their  natural 
laxity,  as  is  sometimes  the  case  in  the  areolar  tissue  of  the  nates  and 
thigh  in  persons  of  13’mphatic  temperament.  This,  indeed,  is  a  difler- 
ence  of  degree  rather  than  of  kind ;  as  pus  would  make  its  appearance 
in  the  course  of  a  few  hours,  if  the  tumor  were  left  to  itself.  The  mere 
occurrence  of  fluctuation,  however,  is  not  of  itself  sufficient  to  determine 
more  than  that  a  fluid  exists  in  the  part.  The  question  necessarily 
arises,  is  this  fluid  pus  ?  In  the  majorit3’-  of  instances,  the  histoiy  of  the 
case,  the  character  of  the  pain,  the  previous  existence  and  the  continu¬ 
ance  of  S3'mptoms  of  inflammation,  enable  the  Surgeon  to  answer  in  the 
affirmative.  But  if,  as  in  chronic  or  cold  abscesses,  there  be  obscure 
evidence  01113'  of  inflammation  having  existed,  and  if  the  swelling  be  of 
long  standing,  the  fluctuation  being  perhaps  deeph'  seated  and  indistinct, 
the  safer  plan  will  be  for  the  Surgeon  to  introduce  an  exploring  needle, 
and  to  see  what  the  true  nature  of  the  fluid  is ;  by  this  simple  means 
man3^  embarrassing  mistakes  in  diagnosis  may  be  avoided. 

The  tumors  with  which  abscesses  ma3'  more  easil3^  be  confounded,  are 
those  soft  solid  groicfhs  in  which  there  is  a  high  degree  of  elasticit3', 
giving  rise  to  a  species  of  undulation,  as  in  some  kinds  of  encephaloid 
tumor.  Fluid  tumors  of  various  kinds,  such  as  cysts  and  enlarged  bursae, 
also  ma3'  be  confounded  with  abscess.  In  these  cases  the  previous 
s3'mptoms,  the  situation,  and  the  general  appearance  and  feel  of  the 
tumor,  will  usuall3'  enable  the  Surgeon  to  effect  a  read3^  diagnosis ;  but 
should  an3'  doubt  exist,  the  exploring  needle  or  trocar  must  be  intro¬ 
duced,  when,  if  pus  be  present,  a  drop  or  two  will  escape.  The  suction- 
trocar”  (Fig.  63),  or  the  “  aspirator,”  an  exhausting  S3U'inge,  is  of 
especial  service  in  cases  in  which  it  is  desirable  to  withdraw  some  of  the 
contained  fluid  for  closer  examination.  The  diagnosis  of  an  abscess 
having  pulsation  communicated  to  it  by  a  subjacent  arter3',  from  an 
aneurism,  will  be  discussed  when  we  come  to  speak  of  that  disease. 

Prognosis. — Abscesses  vaiy  greath'  in  danger,  according  to  their 
nature,  size,  situation,  and  cause,  and  the  constitution  of  the  patient. 
The  chronic  form  is  usually  attended  by  more  risk  than  the  acute  and 
the  diffuse.  The  puerperal  and  p3\mmic  are  especially  hazardous  to  life, 
being  generall3'  associated  with  a  bad  state  of  the  blood.  The.  large  size 


182 


SUPPUKATION  AND  ABSCESS. 


of  some  abscesses  is  an  element  of  great  risk,  occasioning  not  only  a  very 
abundant  discharge  of  pus,  but  likewise  great  constitutional  irritation 
when  the}^  are  opened.  Abscesses  that  are  situated  in  the  neighborhood 
of  important  organs,  as  about  the  neck  of  the  bladder,  or  in  the  anterior 


Fig.  63. 


mediastinum,  are  necessarily  much  more  hazardous  from  the  peculiarity 
of  their  situation  than  those  which  are  met  with  in  less  important 
regions.  The  cause  of  the  abscess  also  influences  the  result ;  if  it  be  a 
piece  of  dead  bone  that  can  be  removed,  the  discharge  will  speedily 
cease  on  its  being  taken  away,  but  if  it  be  so  situated  that  it  cannot  be 
got  rid  of,  it  will,  by  acting  as  a  continuous  source  of  irritation,  keep  up 
a  discharge  that  ma}^  eventually  prove  fatal.  The  constitution  of  the 
patient  influences  our  prognosis.  Such  an  amount  of  discharge  as  would 
inevitably  prove  fatal  in  a  cachectic  system,  ma}^  influence  a  sound  one 
but  very  little ;  so  also,  the  wasting  effect  of  an  abscess  is  better  borne 
about  the  middle  than  at  either  of  the  extreme  periods  of  life. 

Treatment. — The  treatment  of  suppuration  presents  three  points 
requiring  attention.  The  first  object  should  be  to  prevent  the  formation 
of  matter ;  the  next  to  take  steps  for  its  evacuation  when  formed  ;  and 
the  last  to  endeavor  to  close  the  cavity  that  results. 

In  order  to  pre\]ent  the  formation  of  matter^  it  is  necessary  to  get  rid 
of  any  local  irritant  that  may  exist ;  thus  dead  bone  should  l3e  removed, 
or  extravasated  urine  let  out  of  the  areolar  tissue.  After  this  has  been 
done,  the  preventive  treatment  must  consist  in  the  active  employment 
of  local  antiphlogistic  means,  such  as  leeches  and  cold  evaporating 
lotions :  any  slight  tenderness  that  continues  after  the  inflammation  has 
subsided  must  be  removed,  and  the  swelling  from  exudation-matter, 
wdiich  is  especially  the  precursor  of  chronic  abscess,  must  be  got  rid  of 
by  the  continuous  application  of  some  discutient  lotion.  One  composed 
of  iodide  of  potassium  5j?  spirits  of  wine  5j,  water  5vij,  is  extremely 
useful ;  in  some  cases  absorption  may  advantageous!}"  be  promoted  by 
mercurial  ointments  or  plasters.  When  once  pus  has  formed,  it  is  a 
question  whether  it  can  be  absorbed  again ;  in  general,  it  certainly  can¬ 
not,  more  especially  if  once  a  distinct  cyst  have  formed  around  it,  but 
in  some  cases  it  may  undergo  absorption ;  thus,  in  hypop3"on,  we  occa¬ 
sionally  observe  that  the  pus  deposited  in  the  anterior  chamber  of  the 
e3'e  is  removed ;  and  I  think  it  probable  that  the  same  may  happen  when 
it  is  infiltrated  into  the  tissues  of  a  part,  without  a  very  distinct  wall 
surrounding  it.  The  more  fluid  parts  of  chronic  abscesses  occasionally 
become  absorbed,  leaving  a  cheesy  residue,  which  may  degenerate  into 
cretaceous  matter. 

When,  notwithstanding  the  emplo3"ment  of  appropriate  means,  it  is 
evident  that  pus  is  about  to  form,  the  treatment  should  be  completel}" 
changed,  and,  by  the  aid  of  warmth  and  poultices,  an  endeavor  should 
be  made  to  hasten  suppuration.  When  this  is  full}"  established,  the 
abscess  having  become  “  ripe,’’  steps  must  betaken  for  the  evacuation  of 


TREATMENT  OF  ABSCESS. 


133 


the  matter.  The  treatment  of  acute  and  of  chronic  abscesses  differs  in 
some  respects.  In  discussing  the  Treatment  of  Abscess,  we  shall  con¬ 
sider,  in  the  first  instance,  its  management  by  the  methods  ordinarily 
in  use,  and  secondly,  by  the  antiseptic  plan. 

In  the  Acute  Abscess,  the  matter  should  be  let  out  as  soon  as  it  is  fully 
formed,  especially  in  those  varieties  of  the  disease  connected  with  a 
morbid  state  of  the  system,  as  in  the  metastatic  and  puerperal  forms. 
When  this  is  done,  the  constitution  at  once  experiences  great  relief,  the 
fever  and  general  irritation  subsiding  materially ;  the  free  incision  not 
only  letting  out  the  pus  and  l3^mph,  but  removing  tension,  and  by 
encouraging  local  bleeding,  lessening  the  inflammatoiy  action.  The  rule 
of  opening  an  acute  abscess  early  is  especiall}"  imperative  when  the  pus 
is  formed  in  the  sheaths  of  the  tendons  and  under  fibrous  expansions,  as 
in  the  palm  of  the  hand  ;  also  when  it  is  situated  deeply  in  the  areolar 
planes  of  a  limb,  under  the  larger  muscles,  where  it  has  a  tendency  to 
diflfuse  itself  extensively.  In  those  cases,  likewise,  in  which  pus  is  lodged 
in  close  proximity  to  a  joint  or  under  the  periosteum,  it  must  be  let  out 
early  ;  so  also,  when  it  presses  upon  mucous  canals  or  important  organs, 
as  on  the  urethra  or  trachea,  or  when  it  is  dependent  on  the  infiltration 
of  an  irritant  fluid  into  a  part,  as  in  urinaiy  extravasation,  it  must  be 
evacuated  without  delay.  The  pus  should  always  be  let  out  earl}-,  before 
the  skill  covering  it  is  thinned,  when  the  abscess  is  situated  in  the  neck 
or  in  anj’’  other  part  where  it  is  desirable  that  there  should  be  as  little 
scarring  as  possible. 

In  chronic  Abscess,  the  rule  of  surgery  is  not  so  explicit.  Here  the 
collection  is  often  large,  coming  on  without  any  very  evident  symptoms 
and  giving  rise  to  no  material  inconvenience ;  but,  if  it  be  opened,  pu¬ 
trefaction  of  the  pus,  consequent  upon  the  entry  of  air  into  the  extensive 
cyst,  will  give  rise  to  the  most  serious  constitutional  disturbance,  setting 
up  irritative  fever  that  may  rapidly  prove  fatal  in  a  debilitated  frame ; 
and,  should  the  patient  escape  this  danger,  the  drain  of  an  abundant 
suppuration  maj’  speedily  waste  him.  Hence,  it  not  uncommonly  hap¬ 
pens  that  a  patient  maj’  carry  a  chronic  abscess  unopened,  without  any 
very  serious  disturbance,  for  man}"  months  or  even  3"ears ;  but  when  it 
is  once  opened,  he  dies  in  a  few  da3"S.  If,  however,  the  chronic  abscess 
be  so  small  that  no  danger  is  to  be  apprehended  from  the  inflammation 
of  its  C3’st,  or  if  it  be  situated  in  parts  where  it  may  give  rise  to  dan¬ 
gerous  pressure,  the  matter  should  be  let  out  without  dela3^ 

There  are  three  modes  b}"  which  abscesses  may  be  opened,  each  of 
which  possesses  advantages  in  particular  cases  ;  these  are  Incision, 
Tapping  with  a  trocar,  and  making  an  aperture  into  the  cyst  with 
Caustic. 

Incision  is  the  onl}-  plan  that  should  be  practised  in  acute  abscesses. 
For  this  purpose  a  lancet,  an  abscess  bistouiy  (Fig.  64),  or  a  sickle- 


Fig.  64. 


shaped  knife,  ma}-  be  used.  The  incision  should  be  made  either  at  the 
point  where  fluctuation  is  most  distinct,  or  at  the  most  dependent  part 
of  the  tumor,  so  as  to  prevent  after-bagging  of  the  matter.  It  should 
be  made  by  holding  the  bistoury  or  lancet  short,  and  introducing  it  per- 


134 


SUPPURATION  AND  ABSCESS. 


pendicnlarly  into  the  softened  part.  If  the  depth  to  be  reached  be  con¬ 
siderable,  a  bistoury  should  be  used,  the  blade  of  which  should  be  lialf 
turned  round  after  its  introduction,  when  the  pus  wells  up  by  its  side, 
the  point  being  felt  to  move  freely  in  the  cavity  of  the  abscess.  The 
incision  must  then  be  continued  for  a  moderate  extent  in  the  direction 
of  the  natural  folds  of  the  skin  of  the  part,  or  in  the  course  of  the  ves¬ 
sels.  The  pus  should  be  let  out  freely,  so  as  to  allow  the  walls  of  the 
abscess  to  collapse,  but  it  should  not  be  forced  out  by  squeezing  the  sac. 

It  may  happen,  after  the  escape  of  the  pus,  that  the  cavity  of  the 
abscess  is  filled  with  blood  by  the  rupture  of  some  small  vessel  situated 
in  its  w’alls  ;  this,  however,  is  of  little  moment,  the  hemorrhage  speedily 
ceasing  on  the  application  of  pressure,  of  a  bandage,  or  of  cold. 

Provided  the  incision  have  only  to  be  carried  through  the  integu- 
mental  structures  and  fascia,  in  order  to  afibrd  an  outlet  for  the  pus, 
there  can  be  but  little  danger  of  hemorrhage  from  the  accidental  wound 
of  any  bloodvessel  of  importance ;  and,  should  bleeding  occur,  it  will 
probably  be  of  a  venous  character,  and  may  be  arrested  by  pressure  and 
position.  But  when  the  abscess  is  more  deeply  seated  than  this,  lying 
under  the  superficial  muscles,  where  it  will  then  be  necessary  to  penetrate, 
more  serious  consequences  may  ensue,  and  the  incautious  use  of  the 
knife  may  lead  to  the  most  perilous  results.  This  is  more  particularly 
apt  to  happen  in  deeply  seated  periosteal  abscesses  of  the  thigh ;  and  I 
have  more  than  once  known  such  profuse  arterial  hemorrhage  follow 
incisions  made  for  the  purpose  of  evacuating  pus  deeply  lodged  in  the 
limb  in  these  cases,  as  to  necessitate  the  ligature  of  the  femoral  arteiy. 
In  order  to  avoid  this  danger,  Hilton  has  advised  that  abscesses  so 
situated  should  be  opened  in  the  following  way.  An  incision  is  made 
through  the  integuments  and  fascia  so  as  to  expose  the  muscle  under 
which  the  pus  lies;  a  director  is  then  pushed  through  the  substance  of 
the  muscle  into  the  cavity  of  the  abscess,  and  along  the  groove  of  this 
as  a  guide  a  slender  pair  of  dressing-forceps  is  pushed  :  when  it  reaches 
the  abscess  the  blades  are  opened  up,  the  muscular  fibres  separated,  and 
free  exit  given  f  o  the  pus. 

After  the  opening  has  been  made,  a  poultice  or  water-dressing  must  be 
applied.  The  cavity  left  eventually  fills  up  either  by  the  coalescence  of 
its  sides,  or  from  granulating  from  below ;  if  it  fill  again  with  pus,  fresh 
incision,  termed  a  “  counter-opening,”  must  be  made  in  the  most  de¬ 
pendent  part.  Nothing  is  more  dangerous  than  pent-up  matter  in 
imperfectly  opened  abscesses.  It  speedily  decomposes  and  becomes 
offensive,  gives  rise  to  local  irritation  and  infiammation,  and  predisposes 
to  the  occurrence  of  erysipelas  and  pyaemia.  In  order  to  prevent  these 
evil  consequences,  recourse  must  be  had  to  free  openings  in  dependent 
situations,  and  the  use  of  the  drainage-tube. 

In  the  treatment  of  chronic  and  cold  abscess^  any  one  of  these  three 
plans  may  be  employed  for  opening  the  sac.  If  it  be  small,  an  incision 
should  be  made  into  it  at  once.  If  the  collection  be  considerable,  we 
must  wait  until  an  opening  has  been  rendered  necessary  by  the  tendency 
to  implication  of  the  skin,  or  b}^  injurious  pressure  being  exercised  on 
important  parts  ;  the  pus  should  then  be  let  out  by  the  valvular  aperture 
recommended  by  Abernethy,  the  object  being  to  limit  the  entry  of  air 
into  the  interior  of  the  abscess,  so  as  to  lessen  the  chance  of  putrefac¬ 
tion  of  an}^  pus  that  is  left,  and  of  consecutive  infiammation  of  the  cyst. 
The  valvular  opening  is  made  by  drawing  the  skin  covering  the  abscess 
well  to  one  side,  then  passing  the  bistoury  directly  into  the  sac,  and 
allowing  as  much  of  the  pus  to  escape  as  will  flow  out  by  the  collapse  of 


TREATMENT  OF  ABSCESS. 


185 


the  walls  of  the  abscess  ;  before  the  matter  has  quite  ceased  to  flow,  and 
consequently  before  an}'  air  can  have  entered  the  sac,  the  skin  should  be 
allowed  to  recover  its  natural  position,  so  that  the  aperture  in  it  and 
in  the  cyst  may  no  longer  directly  communicate.  A  piece  of  plaster,  or 
of  lint  soaked  in  collodion,  should  be  placed  upon  the  external  wound, 
which  will  probably  heal  under  this  covering  in  the  course  of  a  short 
time.  When  the  cyst  of  the  abscess  has  again  filled  somewhat,  this 
process  may  be  repeated;  so  that,  less  and  less  pus  being  allowed  to 
accumulate  in  it  before  each  succeeding  evacuation,  it  may  gradually  con¬ 
tract  and  close. 

Instead  of  making  the  valvular  opening  in  this  way,  a  chronic  abscess 
may  sometimes  be  advantageously  opened  by  Tapping  loith  a  Trocar 
and  Canula  of  moderate  size,  the  instrument  being  introduced  obliquely 
between  the  skin  and  the  abscess,  and  then  made  to  dip  down  into  the 
sac.  After  the  withdrawal  of  the  canula,  the  aperture  may  be  closed 
as  in  the  former  case.  There  is,  however,  one  disadvantage  in  this  plan 
of  opening  abscesses ;  that  if  the  discharge  be  curdy  or  shreddy,  it  is 
very  apt  to  block  up  the  canula,  and  thus  to  interfere  with  the  proper 
evacuation  of  the  matter.  The  cavity  of  the  abscess  may  sometimes  be 
conveniently  emptied  and  the  pus  sucked  out  by  the  action  of  an  air¬ 
tight  exhausting  syringe,  furnished  with  a  perforating  nozzle — the 
“  aspirator.” 

Fotassa  Fiisa,  though  its  application  be  painful,  may  be  advantageously 
used  for  opening  those  chronic  abscesses,  the  skin  covering  which  is  much 
undermined,  congested,  and  discolored.  In  these  cases  I  commonly 
employ  it  with  great  advantage.  It  is  also  useful  in  the  after-treatment, 
w'hen  much  solid  plastic  matter  is  left,  dissolving  this  away  by  exciting 
inflammation  around  it,  and  thus  preventing  the  formation  of  sinuses 
which  are  otherwise  apt  to  occur. 

In  some  forms  of  abscesses  it  will  be  found  that  those  processes  which 
are  necessary  for  the  contraction  and  closure  of  the  cyst,  after  its  con¬ 
tents  have  been  evacuated,  do  not  readily  take  place  ;  and  it  becomes 
necessary  to  have  recourse  to  other  measures,  in  order  to  excite  sufficient 
healthy  inflammatory  action  to  bring  about  the  closure  of  the  cyst  of  the 
abscess.  With  this  view,  a  Seton  of  two  or  three  threads  may  very 
usefully  be  passed  across  the  cyst  by  means  of  a  nsevus-needle,  or  by  a 
long  straight  needle  pushed  up  through  the  canula  used  for  tapping 
(Fig.  65).  It  should  be  left  in  for  a  few  days,  by  which  time  healthy 


Fig.  65. 


Introduction  of  Seton  through  Canula. 


inflammation  will  be  set  up.  In  other  cases  again,  after  the  cyst  has 
been  tapped,  the  red  wash  or  some  tincture  of  iodine  should  be  injected 
and  left  in.  These  methods  of  exciting  inflammation  are  especially  use- 


186 


SUPPUKATION  AND  ABSCESS. 


ful  when  the  cyst  is  thin,  and  of  a  very  chronic  character.  When  the 
walls  are  very  thick  and  dense,  as  sometimes  happens  in  abscesses  of 
very  old  standing  situated  in  the  neck,  an  elliptical  piece  of  the  anterior 
portion  of  the  C3'st  should  be  dissected  out,  and  the  remainder  of  the 
cavity  be  lightly  dressed  with  lint,  and  allowed  to  hll  by  granulation. 
This  plan  of  treatment  is  often  very  successful ;  and  I  have  by  it  cured 
abscesses  in  the  neck  of  seven  or  eight  years’  standing,  which  have 
resisted  every  other  plan  employed. 

Chassaignac  has  recommended  the  emplo3mient  of  Dy'ainage-tuhes  in 
the  treatment  of  chronic  ahscesHca  of  large  size.  This  method,  which  has 
been  advantageously^  employed  by  many'  Surgeons  in  this  country  of 
late  years,  is  practised  in  the  following  way.  The  abscess  having  been 
punctured,  a  small  India-rubber  tube,  one-sixth  of  an  inch  in  diameter, 
having  several  side  holes  punched  in  it,  is  passed  inW  tlie  cavity',  one 
end  being  allowed  to  hang  out  for  the  pus  to  drain  away'.  These  tubes 

may  very  conveniently  be  introduced  by 
being  fixed  on  to  the  end  of  a  forked  probe 
(Figs.  66,  6t),  by  which  the  tube  is  carried 
into  the  abscess  and  left  there  on  the  with¬ 
drawal  of  the  probe.  Another  plan  consists 
in  passing  the  perforated  India-rubber  tube 
completely’'  across  the  abscess,  drawing  it 
out  through  a  counter-opening,  and  tydng 
the  two  ends  together.  By  this  contrivance 
the  pus  is  carried  off'  by  the  side  of  rather 
than  through  the  tube  as  quickly  as  it  is 
secreted,  the  walls  of  the  abscess  collapse, 
and,  as  gradual  closure  takes  place,  the 
tube  may  be  withdrawn.  In  some  cases  the 
drainage-tubes  have  ai^peared  to  me  to  act 
in  another  way  than  by  merely  removing 
(1  the  purulent  secretion  ;  viz.,  by  irritating 
the  wall  of  the  abscess  just  as  a  seton  would, 
and  thus  setting  up  increased  activity'',  and 
materially  augmenting  the  discharge.  On  their  withdrawal,  however, 
this  stimulation  has  been  found  to  be  beneficial,  causing  a  speedier  clo¬ 
sure  of  the  suppurating  cyst. 

The  antiseptic  treatment  hy  means  of  carbolic  acid  has  been  success¬ 
fully  applied  of  late  y  ears  by  Lister  to  the  cure  of  both  acute  and 
chronic  abscesses.  By  its  means  all  the  advantages  of  a  free  opening, 
giving  ready  exit  to  the  discharges,  can  be  obtained  without  the  dan¬ 
gerous  consequences  which  often  follow  those  methods  of  treatment 
which  have  just  been  described.  The  practice  is  founded  upon  the  fol¬ 
lowing  principles.  1st.  The  formation  of  pus,  whether  on  the  surface 
of  a  granulating  sore  or  in  the  cavity  of  an  abscess,  is  due  to  the 
presence  of  some  abnormal  irritation  of  the  tissues.  2d.  In  the  vast 
majority^  of  cases,  the  primaiy  cause  of  the  formation  of  an  abscess  is 
.of  a  temporary  character,  .its  exact  nature  often  being  uncertain  ;  in 
other  cases  a  distinct  cause  may  be  readily  found,  as  an  injury  in  an 
unhealthy'  subject,  or  the  presence  of  an  irritating  foreign  body,  etc. 
3d.  The  primaiy  cause  of  the  formation  of  an  abscess  being  removed  or 
having  disappeared,  the  irritation  caused  by  the  tension  of  the  parts  in 
consequence  of  the  accumulation  of  fluid  is  sufficient  to  cause  the  con¬ 
tinuance  of  the  process  of  suppuration,  and  the  pointing  of  the  abscess. 
4th.  If  this  cause  of  irritation  be  removed  and  no  other  be  supplied 


Fig.  66. 


Forked  Probe 
for  introducing 
Drainage-tube. 


Fig.  67. 


Drainage- 
an  d  F  0  r  k  e 
Probe. 


ANTISEPTIC  TREATMENT. 


137 


instead,  and  no  other  have  coexisted  with  it  which  will  persist  after  its 
removal, — on  the  relief  of  tension  by  opening  the  abscess,  all  suppura¬ 
tion  will  cease,  the  only  discharge  being  of  a  serous  nature,  coming  from 
the  surface  of  the  granulations  lining  the  cavity  of  the  abscess.  If  this 
be  pent  up  in  the  cavity,  tension  will  be  again  produced,  which,  acting 
as  an  irritant,  will  cause  fresh  suppuration ;  but  if  the  discharge  be 
allowed  to  drain  away  it  will  rapidly  diminish,  and  the  sac  of  the 
abscess  will  be  obliterated  bj"  the  ordinary  processes  of  contraction  and 
cicatrization.  If  dead  bone  exist  at  the  bottom  of  the  cavity  of  the 
abscess,  the  reparative  process,  involving  absorption  of  the  dead  bone, 
will  be  very  slow,  the  serous  discharge  often  continuing  for  months 
without  change,  unless  allowed  to  decompose,  when  it  will  rapidly 
become  purulent  and  enormousl3"  increased  in  quantity.  5th.  In  the 
ordinaiy  method  of  opening  an  abscess,  although  the  irritation  due  to 
tension  is  removed,  a  fresh  irritant  is  admitted  in  the  shape  of  decom¬ 
posing  discharges,  which  in  the  mildest  cases  will  seriously  delay  the 
closing  of  the  cavity  of  the  abscess,  while  in  man)",  such  as  large  psoas 
or  lumbar  abscesses,  it  ma}’  lead  to  such  an  amount  of  constitutional 
disturbance  as  to  be  rapidl}'  fatal.  6th.  The  cause  of  decomposition  is 
not  the  admission  of  the  gases  of  the  air,  but  the  presence  of  organic 
germs  which  are  constantly  floating  in  the  atmosphere,  and  whose 
activit}^  is  readily  destro3’ed  b^^  the  presence  in  the  air  of  a  moderately 
strong  vapor  of  carbolic  acid,  sulphurous  acid,  or  some  other  volatile 
antiseptic.  Lister,  therefore,  in  his  method  of  treatment  aimed  at  the 
following  objects:  1st.  The  free  opening  of  the  abscess,  so  as  completel}" 
to  evacuate  its  contents,  and  to  allow  the  free  drain  of  discharges  after¬ 
wards — that  is  to  say,  the  complete  removal  of  tension  and  the  preven¬ 
tion  of  its  return ;  2d,  that  during  the  whole  treatment  the  opening  into 
the  abscess  shall  never  for  a  single  second  be  exposed  to  air  unmixed 
with  a  strong  vapor  of  carbolic  acid  or  some  other  volatile  antiseptic  ; 
and  3d,  that  all  the  discharges,  as  soon  as  thej'  leave  the  wound,  may 
be  absorbed  b}’  some  porous  material  impregnated  with  some  powerful 
antiseptic — in  short,  the  prevention  of  decomposition  in  the  sac  of  the 
abscess,  or  in  the  discharges  l3'ing  about  the  wound. 

The  antiseptic  which  Lister  has  found  the  most  convenient  for  these 
purposes  is  carbolic  acid.  The  treatment  requires  some  care  in  manage¬ 
ment,  and  must  be  considered  with  minute  attention  to  all  its  details. 
The  materials  required  are  a  solution  of  carbolic  acid  in  water  (1  to 
100),  and  a  solution  in  olive  oil  (I  to  10),  “antiseptic  gauze,”  composed 
of  a  coarse  gauze  impregnated  witli  a  solution  of  carbolic  acid  in 
paraffin  and  resin,  and  a  “  protective,”  consisting  of  oiled  silk  coated 
with  copal  varnish,  and  covered  with  a  thin  la3^er  of  a  mixture  of  dex¬ 
trine  and  starch.  The  object  of  these  various  materials  is  as  follows. 
The  wateiy  solution  is  used  when  the  action  required  is  not  of  long 
duration,  but  when  a  vapor  of  carbolic  acid  is  intended  to  be  kept  up 
round  an  open  wound,  the  wateiy  solution  veiy  readil3"  parting  with  its 
carbolic  acid.  It  ma3"  be  used  in  two  wa3’s,  either  as  a  spra3’^  blown 
upon  the  part  from  an  ether-spra3^  apparatus,  or  b3*  means  of  a  piece  of 
linen  rag  soaked  in  the  lotion  and  laid  over  the  open  wound  while  the 
more  permanent  dressings  are  being  prepared.  The  oil3'  solution  retains 
its  carbolic  acid  much  more  Arm  13%  and  ma3'  be  used  where  the  action 
is  required  to  be  more  prolonged,  or  in  the  fresh  opening  of  an  abscess 
where  the  rush  of  pus  might  wash  the  wateiy  solution  out  of  the  piece 
of  rag  placed  over  the  wound.  It  is  also  used  for  greasing  the  parts 
round  the  abscess,  especiall3’  if  veiy  dirt3’  or  haiiy,  and  for  greasing  any 


138 


SUPPUKATION  AND  ABSCESS. 


instrument  to  be  used  during  the  operation,  or  the  Surgeon’s  finger,  if 
he  intend  to  introduce  it  into  the  cavity  of  the  abscess.  The  “antiseptic 
gauze”  retains  the  carbolic  acid  much  more  firmly  than  the  oily  solu¬ 
tion,  continuing  to  give  off  a  vapor  of  the  acid  for  many  months,  even 
when  exposed  ft’eel}^  to  the  air.  It  is  intended  to  be  placed  over  the 
wound  to  absorb  any  discharge  from  it,  and  to  keep  it  free  from  decom¬ 
position.  Its  action  is  exactly  the  same  as  that  of  carded  oakum,  and 
it  is  more  cleanly,  more  easily  applied,  and  more  certain  in  its  action. 
The  “  protective  ”  is  a  substance  impermeable  to  carbolic  acid,  intended 
to  be  placed  over  a  granulating  wound  in  order  to  prevent,  as  far  as  pos¬ 
sible,  the  direct  contact  of  the  carbolic  acid,  which,  acting  as  a  powerful 
irritant,  would  arrest  or  at  least  delay  healing,  and  cause  profuse  sup¬ 
puration.  It  is  used  over  granulating  sores  left  after  opening  abscesses, 
etc.,  when  it  is  thought  desirable  that  the}'  should  heal.  It  is  soaked  in 
carbolic  acid  and  water  (I  to  100)  before  it  is  applied,  so  as  to  destroy 
any  germs  that  ma}'  be  resting  upon  it ;  and,  after  application,  the 
small  proportion  of  carbolic  acid  on  its  surface  being  rapidly  absorbed 
by  the  sore  beneath,  it  is  left  almost  perfectly  free  from  an}'  irritating 
qualities. 

The  opening  of  an  abscess,  according  to  the  antiseptic  method,  is, 
therefore,  done  as  follows.  The  skin  all  around  for  at  least  nine  inches 
being  well  greased  with  the  oily  solution,  a  spray  of  the  watery  solution 
is  blown  upon  the  part  where  the  incision  is  to  be  made,  and  the  abscess 
is  opened  with  a  knife  which  has  also  been  dipped  in  the  oily  solution. 
The  pus  in  the  abscess  being  squeezed  out,  a  plug  of  lint  soaked  in  the 
oily  solution  or  a  piece  of  the  gauze  soaked  in  either  the  watery  or  the 
oily  solution,  is  pushed  into  the  opening  so  as  to  act  as  a  drain,  and 
allow  the  escape  of  the  serous  discharge,  for  the  first  few  days ;  or  an 
India-rubber  drainage-tube,  soaked  in  carbolic  acid,  may  be  used  as 
before  described  in  the  ordinary  treatment  of  abscesses.  The  part  is 
then  wrapped  in  the  gauze,  folded  eight  layers  thick  and  extending  six 
or  eight  inches  or  more,  according  to  the  amount  of  discharge,  on  each 
side  of  the  opening ;  the  spray  must  be  kept  up  until  the  whole  part  is 
enveloped  in  the  gauze.  Over  this  dressing  must  be  put  a  piece  of  gutta¬ 
percha  tissue,  or  of  thin  macintosh  cloth  dipped  in  carbolic  acid  and 
water,  so  that  the  discharge  may  not  soak  through  at  one  spot  and 
decompose,  but  may  be  evenly  diffused  over  the  whole  of  the  dressing. 
Over  this  water-proof  material  a  bandage  composed  of  the  antiseptic 
gauze  may  be  placed,  and  over  all  a  common  bandage  if  it  be  thought 
necessary.  If  the  spray-apparatus  be  not  at  hand,  or  if  there  be  no 
assistant  to  work  it,  the  same  objects  may  be  attained  by  the  judicious 
use  of  a  piece  of  rag  soaked  in  the  oily  solution.  It  must  be  held  over 
the  part  where  the  opening  is  being  made,  and  dropped  on  immediately 
it  is  completed,  and  the  pus  squeezed  out  from  underneath  it.  The 
dressing  can  then  be  put  on  over  it,  a  corner  of  it  being  left  exposed  by 
which  it  can  be  drawn  out  as  soon  as  the  gauze  is  firmly  over  the  opening. 
During  the  after-dressings  it  is  hardly  necessary  to  use  a  rag  soaked  in 
the  oily  solution,  unless  the  discharge  be  very  profuse;  for,  as  the  time 
occupied  is  very  short,  a  piece  of  linen  soaked  in  the  watery  solution 
will  answer  all  the  purposes  required.  It  must  be  put  over  the  whole 
part  where  the  incision  is,  and  the  dressing  removed  from  under  it  with¬ 
out  exposing  the  wound  to  the  air  at  all.  If  it  be  desirable  to  look  at 
the  opening,  the  rag  may  be  raised  while  a  small  stream  of  carbolic  acid 
and  water  is  run  over  the  wound  by  means  of  a  syringe,  an  Esmarch’s 
irrigator,  or  a  sponge.  The  dressings  should  be  repeated  on  the  day 


HEMORRHAGE  INTO  ABSCESSES. 


139 


after  the  opening  of  the  abscess,  and,  after  that,  every  alternate  day,  or 
every  third  or  fourth  day,  according  to  the  amount  of  discharge. 

It  is  not  to  be  imagined  that  in  all  cases  this  mode  of  treatment  will 
entirely  prevent  the  formation  of  pus  after  the  opening  of  an  abscess,  as, 
although  tension  may  be  removed  and  decomposition  ma}’  be  prevented, 
other  causes  of  irritation  may  be  present ;  but,  in  all  cases,  the  consti¬ 
tutional  disturbance  will  be  greatly  diminished  by  the  prevention  of  the 
irritation  necessaril}-  resulting  from  the  presence  of  fetid  discharges  in 
the  cavity  of  the  abscess  and  about  the  wound.  If  the  discharge  do  not 
escape  freel}’^  a  common  India-rubber  drainage-tube  may  be  inserted,  after 
being  soaked  for  24  hours  in  a  concentrated  wateiy  solution  of  carbolic 
acid.  If,  as  occurs  in  rare  cases,  decomposition  has  occurred  in  the 
abscess  before  it  is  opened,  it  may  be  corrected  by  injecting  the  sac  of 
the  abscess  with  some  antiseptic  agent,  and  for  this  purpose  chloride  of 
zinc,  40  gr.  to  ^i  of  water,  will  usually  be  found  the  most  effectual. 

Of  the  great  value  of  this  method  of  treatment,  more  especiall}''  in  the 
case  of  chronic  and  cold  abscess,  there  can  be  no  doubt  in  the  mind  of 
any  one  wdio  has  given  it  a  fair  trial.  By  the  “  Antise2:)tic  Method,” 
properly  carried  out,  and  in  accordance  with  a  scrupulous  attention  to 
those  details  that  are  necessary  for  its  successful  employment,  it  will  be 
found  that  the  formation  of  pus  speedily  diminishes,  that  the  danger  of 
its  decomposition  is  removed,  and  that  the  chance  of  constitutional  irri¬ 
tation  is  consequently  greatly  lessened  if  it  be  not  entirely  removed — 
that  those  dangers,  in  fact,  which  are  apt  to  result  from  the  opening  up 
of  large  suppurating  cavities  are  greatly  obviated  by  the  use  of  anti¬ 
septic  dressings. 

Constitutional  Treatment. — With  the  view  of  preventing  the  occur¬ 
rence  of  suppuration,  we  must  be  careful  to  maintain  the  powers  of  the 
system,  and  not  to  reduce  the  patient  too  much,  even  if  the  inflamma¬ 
tion  be  of  a  sthenic  character  at  the  outset.  Suppuration  is  a  condition 
of  debilit}^  and  is  especially  predisposed  to  by  any  previously  existing 
enfeebled  state  of  the  system,  or  b}'’  malnutrition.  Another  reason  for 
the  avoidance  of  the  earl3^  emplo^'ment  of  debilitating  means  is  that,  if 
suppuration  once  be  established,  the  drain  on  the  S3^stem  may  eventually 
be  so  considerable  as  to  require  all  the  patient’s  powers  to  enable  him 
to  bear  up  against  it.  Hence  the3^  should  be  husbanded  from  the  first. 
After  the  discharge  has  taken  place,  nourishing,  tonic,  and  even  stimu¬ 
lating  treatment  will  be  required  in  proportion  to  the  amount  of  debility 
that  is  induced.  Amongst  the  most  useful  medicinal  agents  are  mineral 
and  vegetable  tonics,  the  mineral  acids,  and  cod-liver  oil  in  the  more 
chronic  stages.  Attention  to  h3'gienic  conditions,  with  change  of  air, 
and  residence  at  the  sea-side,  is  also  most  valuable.  When  hectic  comes 
on,  the  same  general  tonic  plan  must  be  adopted,  while  we  have  recourse 
to  means  adapted  to  meet  the  local  symptoms.  Thus,  acids  are  required 
to  check  the  sweating,  astringents  to  arrest  the  diarrhoea,  and  as  much 
mild  nourishment  as  the  patient  will  bear  to  support  the  strength. 

Hemorrhage  into  the  Cavity  of  an  Abscess  is  not  of  unfre¬ 
quent  occurrence.  It  may  arise  from  three  sources:  I.  Oozing  of 
blood  from  the  vascular  wall  of  the  abscess;  2.  An  ulcerated  vein; 
3.  Ulceration  or  sloughing  of  the  coats  of  a  neighboring  artery. 

The  bleeding  which  occurs  from  the  Abscess-wall  is  the  most  frequent, 
and  the  least  important.  It  sometimes  takes  place  before  the  abscess 
is  opened,  the  pus  that  escapes  being  then  found  to  be  sanious  and 
mixed  with  small  coagula.  More  commonly  it  occurs  after  the  opening 
of  the  abscess,  in  consequence  probably  of  its  wall  having  lost  the  sup- 


140 


SUPPURATION  AND  ABSCESS. 


port  of  the  contained  pus,  when  the  vessels  in  the  soft  plastic  and  very 
vascular  lining  give  way,  and  the  cavity  speedily  fills  with  blood.  In 
these  cases  the  hemorrhage  may  always  be  arrested  by  laying  open 
freely  the  cavity  of  the  abscess,  turning  out  the  coagula,  stuffing  it  with 
strips  of  lint,  and  applying  pressure  with  a  bandage.  It  usually,  how¬ 
ever,  ceases  of  itself  as  soon  as  the  cavity  has  been  freely  opened  up 
and  the  exterior  exposed  to  cold  air. 

Hemorrhage  from  Ulceration  extending  into  a  neighboring  Vein^  is 
necessarily  far  more  serious.  It  has  usually  happened  from  sloughy 
abscesses  formed  on  the  side  of  the  neck  or  under  the  angle  of  the  jaw, 
as  a  consequence  of  scarlatina  in  strumous  and  unhealthy  individuals, 
opening  up  the  internal  jugular  vein.  But  it  may  arise,  independently 
of  any  specific  inflammation,  in  cachectic  patients.  In  these  distressing 
cases,  the  only  treatment  that  can  be  adopted  is,  to  plug  the  cavity  of 
the  abscess  with  lint  soaked  in  a  solution  of  the  perchloride  of  iron,  and 
supported  by  bandage  or  plasters.  In  this  way  the  fatal  event  may  be 
for  a  time  perhaps  delayed ;  but  it  is  inevitable  ultimately,  the  blood 
bursting  forth  by  the  sides  of  the  plugs  as  these  become  loosened,  or  as 
the  sloughing  action  opens  up  the  vein  more  widely.  The  fatal  effect  of 
the  bleeding  is  greatl_y  aggravated  by  the  depressed  state  of  the  sj’^stem, 
laboring  under  the  conjoined  influences  of  a  large  infiltrated  and  sloughy 
wound  and  of  a  specific  poison. 

If  the  hemorrhage  arise  from  the  Ulceration  of  a  large  Artery^  the 
case  necessarily  becomes  one  of  extreme  urgency.  I  have  known  this 
condition  to  occur  in  the  neck  and  in  the  thigh;  in  the  neck  from 
sloughy  scarlatinal  abscess  implicating  the  carotid ;  in  the  thigh,  from 
the  extension  of  ulcerative  action  from  abscess  and  sinuses  to  the  deep 
femoral.  When  this  untoward  complication  of  abscess  occurs  in  the 
neck,  the  hemorrhage  is  usually  so  sudden  and  so  profuse  that  the  Sur¬ 
geon  has  not  time  to  tie  the  carotid  before  life  is  extinguished.  In  the 
thigh  the  case  is  not  so  urgent.  Warnings  by  repeated  small  hemor¬ 
rhages  may  have  enabled  the  Surgeon  to  adopt  means  to  restrain  the 
bleeding;  and,  in  the  case  to  which  I  allude,  that  of  a  young  man,  the 
femoral  artery  was  tied  successfully.  In  these  cases,  it  is  worse  than 
useless  to  trust  to  secondary  means  for  the  arrest  of  the  bleeding. 
When  practicable,  the  artery  should  be  compressed,  the  cavity  freely 
opened  up,  and  the  bleeding  vessel  sought  for  and  tied.  If  it  cannot  be 
found,  the  main  trunk  must  be  ligatured;  and  for  obvious  reasons  this 
is  the  only  course  that  can  be  pursued  in  the  neck. 

Sinus  and  Fistula. — A  fter  an  abscess  has  been  opened,  its  cavity 
may  not  fill  up  completely,  but,  contracting  into  a  narrow  suppurating 
track,  may  form  a  canal  without  disposition  to  close,  and  from  which  a 
small  quantity  of  pus  constantly  exudes,  thus  constituting  a  Sinus  or 
Fistula. 

The  Causes  of  this  non-closure  of  the  cyst  of  an  abscess  may  be 
referred  to  the  following  heads : — I.  The  presence  of  a  foreign  bodj^,  as 
of  a  piece  of  dead  bone  at  the  bottom  ;  2.  The  passage  of  irritating  secre¬ 
tions,  as  of  urine,  feces,  saliva,  &c.,  through  the  abscess;  and  3.  The 
contraction  of  neighboring  muscles;  as  when  the  abscess  is  in  the  neigh¬ 
borhood  of  the  sphincter  ani,  and  as  occasionally  happens  in  abscesses 
about  the  limbs. 

Structure. — A  sinus  or  fistula  consists  of  a  narrow  channel,  often  long 
and  winding,  having  an  external  orifice  usually  somewhat  protuberant, 
being  situated  under  or  among  loose  florid  granulations.  The  walls  of 
this  channel,  which  are  always  indurated,  are  lined  by  a  structure 


ULCERATION. 


141 


resembling  mucous  membrane;  this,  however,  it  is  not,  but  simplj’-  con¬ 
sists  of  a  la3’er  of  imperfectl}’’  formed  granulations,  exuding  ichorous 
pus.  If  the  orifice  be  occluded,  this  pus  will  collect  within  the  sinus, 
and  distending  its  walls,  reconvert  it  into  an  abscess.  In  structure, 
therefore,  a  sinus  or  fistula  may  be  said  to  be  a  long,  narrow,  chronic 
abscess,  with  a  permanent  external  aperture. 

The  Treatment  of  a  sinus  or  fistula  has  reference  to  its  cause  in  the 
first  instance;  for,  until  the  foreign  bodj"  that  keeps  it  open  and  main¬ 
tains  the  discharge  has  been  removed,  it  will  be  useless  to  attempt  its 
closure.  After  the  removal  of  the  obstacle  to  healing,  we  may  endeavor 
to  procure  obliteration  of  the  sinus  b}^  one  of  three  methods. 

1.  Pressure^  b}^  means  of  a  roller  and  graduated  compress,  so  as  to 
cause  an  agglutination  of  its  opposite  sides,  is  useful  in  those  cases  in 
which  the  sinus  is  recent,  without  much  surrounding  induration,  and  so 
situated,  as  upon  the  trunk,  that  pressure  can  easily  be  applied. 

2.  A  more  health}^  inflammation  may  often  usefull}"  be  excited  in  the 
sinus,  b}”  injecting  it  from  time  to  time  with  “red  wash”  or  with  tinc¬ 
ture  of  iodine,  b}^  passing  the  threads  of  a  seton  through  it,  or  b}’’ 
stimulating  it  b}'  the  occasional  contact  of  a  red-hot  iron.  Marshall  has 
invented  a  veiy  ingenious  and  useful  apparatus,  by  means  of  which  a 
platinum  wire,  introduced  cold,  is  heated  red-hot  b}"  the  galvanic  cur¬ 
rent.  This  galvanic  cautery  ma^'  often  be  emplo^’ed  with  much  success 
in  the  treatment  of  fistulm  and  sinuses,  to  which  other  methods  are  not 
veiy  applicable. 

3.  The  last  method  consists  in  laying  open  the  sinus  from  end  to 
end,  and  then  dressing  the  wound  so  that  it  may  heal  from  the  bottom  ; 
in  this  wa3",  neighboring  muscles,  that  have  kept  it  open  b}"  their  con¬ 
tractions,  may  also  be  set  at  rest.  The  division  of  the  sinus  should  be 
made  with  a  probe-pointed  bistour}',  introduced  through  the  external 
opening  either  b}"  the  aid  of  a  director  or  without  such  assistance.  The 
operation  should  be  done  effectually,  the  sinus  being  usualh^  followed  as 
far  as  is  prudent,  and  laid  completeh"  open. 


CHAPTER  YI. 

ULCERATION. 

Ulceration  is  that  process  b3’  which  there  is  produced  a  solution  of 
continuit}’’  with  loss  of  substance,-  attended  with  the  secretion  of  pus. 
It  may  either  be  the  result  of  some  influence  acting  in  the  part  itself,  or 
of  the  destruction  of  the  part  b}'  the  sudden  application  of  chemical 
agents.  There  are  two  distinct  stages  described  as  constituting  the 
process  of  ulceration,  attended  b}’ the  most  opposite  phenomena;  viz., 
1,  the  period  of  Destruction ;  2,  the  period  of  Reparation.  To  the  first 
onl}’-  can  the  term  be  properl}'  applied,  the  stage  of  repair  being  one  of 
deposition.  The  term  ulceration  is  applied  to  the  destruction  of  super¬ 
ficial  tissues,  although  it  ma}'  be  regarded  as  having  a  close  analogy 
with  the  destruction  of  tissue  which  attends  suppuration  within  the 
texture  or  substance  of  parts.  It  is  most  common  on  the  cutaneous  and 
mucous  surfaces,  but  likewise  occurs  on  the  lining  membrane  of  blood¬ 
vessels  and  on  serous  membranes. 


142 


ULCERATION. 


Ulceration  is  so  intimately  allied  with  sloughing  and  gangrene,  that 
it  is  very  difficult  to  separate  its  causes  from  those  of  these  other 
conditions. 

Causes. — The  Predisposing  Causes  of  Ulceration  are  chiefly  found 
in  those  conditions  that  interfere  in  aii}^  wa}^  with  the  nutrition  of  a 
part.  A  feeble  circulation,  such  as  often  exists  in  the  lower  limbs,  in  the 
alie  of  the  nose,  and  in  newl}"  formed  or  recently  cicatrized  parts,  tends 
to  the  formation  of  ulcers.  As  ao:e  advances,  nutrition  becoming  im- 
paired  and  the  circulation  less  active,  slight  causes  suffice  to  disintegrate 
the  structure  of  a  part;  and  malnutrition,  or  loss  of  innervation  from 
any  cause,  by  lessening  the  vitality  and  resisting  power  of  tissues,  has 
a  tendency  to  give  rise  to  ulceration.  Hence  we  so  commonly  see 
ulcers  of  the  legs  in  elderly  people,  more  particularly  amongst  the  poorer 
classes,  arise  from  slight  irritation  or  pressure.  In  the  dogs  that  Ma- 
gendie  starved  by  feeding  them  on  sugar,  gum,  or  oil  and  distilled  water, 
ulceration  of  the  cornea  occurred.  This  must  have  been  the  result  of 
simple  malnutrition,  rather  than  of  inflammation. 

Tissues  that  have  been  congested  for  a  long  time  are  apt  to  inflame 
under  the  influence  of  some  trivial  exciting  cause,  and  rapidly  to  run 
into  ulceration.  This  usually  commences  in  the  centre  of  the  part,  where 
the  nutrient  action  is  lowest ;  here  a  small  sure  forms,  which  exudes  thin 
unhealthy  pus,  and  rapidl}’’  extends.  So  long  as  the  sore  is  inflamed,  it 
continues  to  spread,  and  reparation  cannot  go  on  in  it.  It  would  appear 
as  if  a  moderate  degree  of  inflammation  were  too  intense  for  the  vitality 
of  chronically  congested  tissues,  or  of  those  in  which  lowly  organized 
fibrine  has  been  etfused.  The  more  the  vitalit}^  of  a  tissue  is  reduced, 
the  less  appears  to  be  the  degree  of  inflammation  that  is  required  to 
produce  disintegration  and  ulceration  of  it.  Indeed,  if  the  vitality  of  a 
part  be  sufficientl^Aowered,  it  may  fall  into  a  state  of  ulceration  without 
the  occurrence  of  inflammation,  or  with  so  slight  a  degree  as  scarcely  to 
be  appreciable :  the  ulcerative  action  appearing  to  rise  from  disintegra¬ 
tion  dependent  upon  the  want  of  nutrition.  Thus,  for  instance,  in  scro¬ 
fula  and  in  other  diseases,  as  scurv}'  or  S3q3hilis,  where  there  is  an 
imperfect  nutritive  force,  a  tendenc}'  to  softening  and  breaking  down  of 
structure,  and  consequent  ulceration,  occurs  ;  and  this  tendency"  is  much 
increased  b^"  the  occurrence  of  congestive  or  subacute  inflammation  in 
the  part. 

Ulceration  ma}’’  be  directly  excited  in  several  distinct  waj^s  on  the 
cutaneous  and  the  mucous  surfaces. 

1.  There  may  be  such  a  degree  of  acute  local  inflammation  as  rapidly 
gives  rise  to  molecular  death  of  the  part.  If  the  action  be  not  very 
acute,  and  the  destruction  of  the  tissues  not  veiy  rapid  or  extensive,  the 
disorganized  matters  become  mixed  with  pus,  and  are  discharged  in  the 
form  of  a  dirt}',  brownish,  puriform  fluid.  If  the  action  be  more  violent 
than  this,  complete  disintegration  does  not  take  place  in  the  affected 
part,  but  shreds  of  the  spoilt  tissues  continue  attached  for  some  time 
to  the  ulcerated  surface,  giving  it  a  very  ragged  appearance.  If  the 
inflammation  be  more  intense,  layers  of  disorganized  tissue,  constituting 

sloughs,”  are  formed,  and  remain  in  contact  with  the  ulcerated  surface, 
often  covering  it  in  completely,  and  invading  with  considerable  rapidity 
tlie  neighboring  healthy  structures.  Thus  some  of  the  forms  of  phage- 
daenic  or  sloucrhing  ulcer  are  constituted. 

2.  Chronic  inflammation  is  perhaps  the  most  common  cause  of  ulcera¬ 
tion.  The  process  of  formation  of  an  ulcer  under  this  condition  has 
been  well  described  by  Billroth.  “  Let  us  suppose,”  he  says,  “  that  we 


SITUATION. 


143 


have  a  chronic  inflammation  of  the  skin  of  the  leg,  say  on  the  anterior 
surface  of  its  lower  third.  The  skin  is  traversed  by  dilated  vessels,  hence 
it  is  redder  than  usual ;  it  is  swollen,  partly  from  serous,  partly  from 
plastic  infiltration;  and  it  is  sensitive  to  pressure.  Wandering  cells  are 
infiltrated,  especially  in  the  superficial  parts  of  the  cutis :  this  renders 
the  papillfB  longer  and  more  succulent :  the  development  of  the  cells  of 
the  rete  Malpighii  also  becomes  more  plentiful,  and  its  superficial  la3’ers 
do  not  pass  into  the  normal  hornj'  state  ;  the  connective  tissue  of  the 
l^apillaiy  layer  is  softer,  and  becomes  partly  gelatinous.  Now,  slight 
friction  at  any  point  suflflces  to  remove  the  soft  thin  horn}’’  laj’er  of  the 
epidermis.  This  exposes  the  cell-la3"er  of  the  rete  Malpighii ;  new  irri¬ 
tation  is  set  up,  and  the  result  is  a  suppurating  surface,  whose  upper 
layer  consists  of  wandering  cells,  the  lower  of  greatly  degenerated  and 
enlarged  cutaneous  papillm.  If  at  this  stage  the  part  were  kept  at  per¬ 
fect  rest,  and  protected  from  further  irritation,  the  epidermis  would  be 
graduall}’’  regenerated,  and  the  still  superficial  ulcer  would  cicatrize. 
But  usuall}’’  the  slight  superficial  wound  is  too  little  noticed,  it  is  ex¬ 
posed  to  new  irritations  of  various  kinds  ;  there  are  suppuration  and 
molecular  destruction  of  the  exposed  inflamed  tissue,  then  of  the  papillae, 
and  the  result  is  a  loss  of  substance  which  graduall}'  grows  deeper  and 
wider:  the  ulcer  is  fully  formed.” 

3.  Ulceration  sometimes  commences  in  the  crypts  or  follicles  which 
open  on  the  mucous  surface,  some  modification  of  structure  taking  place 
in  their  epithelial  linings,  which  leads  to  the  formation  of  circular  de¬ 
pressed  ulcers. 

4.  A  vesicle  or  pustule  forming  on  the  cutaneous  surface,  and  shed¬ 
ding  its  contents,  veiy  commonl}’’  gives  rise  to  an  ulcer,  as  in  rupia  and 
pemphigus. 

5.  Suppurative  inflammation  not  unfrequently  occurs  in  the  subcuta¬ 
neous  or  submucous , areolar  tissues,  and,  ly  undermining  and  conse¬ 
quently  destro3dng  the  vascularity'  of  the  skin  and  mucous  membrane, 
and  thus  arresting  its  nutrition,  gi'^»es  rise  to  ulcer. 

6.  Ulceration  may'  be  produced  by  a  severe  mechanical  injury',  by'  long 
continued  pressure,  or  by  the  action  of  an  irritant,  producing  a  direct 
breach  of  surface. 

U  In  some  specific  cases,  ulceration  is  preceded  by^  the  formation  of  a 
morbid  growth,  tubercle  or  tumor,  in  which  inflammation  and  disintegra¬ 
tion  of  tissue,  and  consequent  lesion  of  substance,  occur. 

Situation. — Ulcers  may  be  situated  upon  any'  part  of  the  cutaneous 
surface  as  the  result  of  violence;  most  commonly',  when  arising  from 
some  specific  affection  they'  occur  in  particular  situations,  as  on  the 
penis,  lips,  tongue,  &c. ;  but  when  they' occur  from  disease  of  non-specific 
character  they  are  usually'  seated  on  the  leg.  It  is  the  lower  half  of  the 
leg  that  is  the  common  seat  of  these  simple  ulcers,  w'hich  there  occur  in 
every'  possible  variety.  They  are  most  common  at  or  after  the  middle 
period  of  life,  and  are  more  frequently'  met  with  in  the  poorer  classes. 
They  are  especially  predisposed  to  by  all  those  circumstances  that  favor 
weakness  of  circulation,  and  consequently  low'  vitality'  of  the  part — as 
exposure  to  cold  and  w'et,  w'ant  of  food,  &c.  The  skin  of  the  low'er  part 
of  the  leg  is  prone  to  these  ulcerations,  in  consequence  of  its  natural 
thinness,  the  feebleness  of  its  circulation,  more  especially  in  advanced 
life,  and  its  liability'  to  venous  congestions  from  position.  Ulcers  that 
once  form  here  are  slow  in  healing  and  very  liable  to  recurrence,  for  the 
same  reasons  that  lead  to  their  formation,  coupled  w'ith  the  absence  of  a 
proper  subcutaneous  areolo-adipose  bed,  and  the  consequent  tendency'  of 


144 


ULCERATION. 


adhesion  of  the  under  surface  of  the  ulcer  to  the  aponeurosis  or  perios¬ 
teum. 

Stages. — In  whatever  way  ulceration  commences,  it  presents  three 
distinct  stages;  viz.,  1,  Extension  or  Slough;  2^  Arrest  with  Deposit 
of  Plastic  Matter  ;  and  3,  Repair  by  Granulation  and  Cicatrization, 

1.  When  the  ulcer  is  Spreading ,,  there  is  always  a  circle  of  inflamma¬ 
tion  arouud  it,  as  evinced  by  redness,  heat,  and  a  burning,  throbbing 
pain;  its  edges  are  jagged,  eroded,  or  sharp  cut;  its  surface,  which  is 
more  or  less  circular  or  oval,  spreads  nearly  equally  from  one  starting- 
point,  and  is  covered  with  a  gra3dsh  or  yellowish,  soft,  adherent  slough. 
In  ordinaiy  cases  this  is  thin  and  shreddy,  but  in  some  forms  of  ulcera¬ 
tion  it  is  soft,  pultaceous,  and  elevated  above  the  surrounding  parts. 
There  is  either  no  discharge  at  all,  or  else  a  bloody,  ill-conditioned  fluid, 
liardl^^  deserving  the  name  of  pus,  drains  from  the  surface. 

2.  In  the  next  stage,  that  of  Arrest,,  the  s3’mptoms  of  inflammation 
diminish,  and  a  la3mr  of  plastic  matter  is  deposited  in  the  tissues  forming 
the  base  and  sides  of  the  ulcer.  This  not  onl3^  serves  to  arrest  or  limit 
the  further  process  of  ulceration,  but  becomes  the  medium  of  ultimate 
repair.  The  surface  begins  to  clean,  the  gray  adherent  slough  sepa¬ 
rating  in  fragments  and  dissolving  away  in  the  discharge,  which  gradu¬ 
ally  loses  its  sanious  tinge,  and  assumes  more  the  character  of  liealth3^ 
pus,  though  still  very  scant3^  in  quantity.  The  surface  continues  flat¬ 
tened,  its  sensibilit3'  diminishes,  and  the  edges  are  often  elevated  and 
indurated.  In  this  stationary  condition  an  ulcer  may  remain  for  many 
months ;  and  it  is  that  in  which  we  commonl3^  find  chronic  sores. 

3.  The  last  stage,  that  of  Repair,,  is  characterized  b3^  the  formation  of 
granulations,  which  may  be  looked  upon  as  the  turning  point  in  ulcera¬ 
tion.  Until  granulations  are  formed,  ulceration  is  a  wasting  process,  or 
at  most  stationary ;  so  soon  as  they  are  formed,  repair  commences. 
Instead  of  a  tendenc3'  to  increase,  to  erosion,  and  to  concavity,  we  now 
find  a  disposition  to  contraction,  to  deposition,  and  to  convexity  of  the 
surface,  which  assumes  a  bright  red  hue,  of  a  vermilion  or  scarlet  tinge, 
appearing  to  be  studded  with  minute  papillae ;  the  edges  become  rounded 
and  smoothed  down  towards  the  surface,  losing  their  sharp  cut  appear¬ 
ance  ;  and  the  discharge  assumes  the  characters  of  health3'’  pus. 

Repair  of  Ulcers. — We  now  proceed  to  study  the  changes  that 
occur  in  an  ulcer  during  the  stage  of  repair — the  processes  of  Granula¬ 
tion  and  of  Cicatrization. 

Granulation, — So  soon  as  inflammation  and  extension  of  ulceration 
are  checked,  the  surface  of  the  ulcer,  as  has  already  been  stated,  becomes- 
covered  b3’’  a  layer  of  plastic  matter.  This  plastic  layer,  separating  the 
ulcer  from  surrounding  and  adjacent  tissues,  forms  a  basis  from  which 
the  granulations,  the  organs  of  repair,  spring  up.  Before  this  plastic 
basis  can  be  deposited,  it  is  necessary  that  the  inflammation  be  reduced 
within  those  limits  that  are  compatible  with  plastic  effusion.  So  long 
as  inflammatoiy  action  exceeds  this  limit  around  the  edge  or  at  the  base 
of  the  ulcer,  no  lymph  is  effused.  But  as  soon  as  this  undue  action  is 
checked,  l3nnph  is  thrown  out,  which  becomes  vascularized  hy  vessels 
shooting  into  it  from  below;  and  assumes  a  granular  form  from  its  depo¬ 
sition  in  papillae,  or  granulations,  which  are  thus  composed  of  exudative 
matter  that  has  become  vascularized.  In  the  great  majority  of  cases, 
granulations  are  formed  01113’^  on  surfaces  exposed  to  the  air  and  secreting 
pus ;  but  they  ma3^  be  formed  without  exposure  to  the  air  or  the  forma¬ 
tion  of  pus,  as  Hunter  and  Paget  have  shown  to  occur  in  some  cases  of 
fracture,  the  ends  of  the  bones  being  covered  b3^  a  distinct  la3'er  of  florid 


REPAIR  OF  ULCERS. 


145 


granulations.  That  these  granulations  are  in  reality  composed  of  lymph 
that  has  become  vascular,  is  evident  from  the  interesting  fact  observed 
by  Hunter,  and  which  every  Surgeon  must  have  had  repeated  occasion 
to  verify,  both  in  wounds  and  in  compound  fractures — that  a  portion  of 
bluish-white  semitransparent  lymph  effused  on  the  surface  of  the  sore 
or  denuded  bone  is  seen  to  become  vascularized,  and  to  be  converted 
into  true  granulations,  in  from  twenty-four  to  forty-eight  hours. 

The  microscope  shows  that  granulations  are  composed  of  cells  heaped 
up  without  much,  if  any,  apparent  order,  and  connected  b}"  but  little 
intermediate  substance.  lYhen  single,  the}-  are  colorless ;  when  in  clus¬ 
ters,  they  become  rudd}".  It  is  interesting  to  observe  how'  these  cells 
undergo  different  changes  in  different  parts  of  the  same  ulcer.  Those 
situated  at  the  base  nearest  the  attached  surface  of  the  granulation, 
constituting  its  deeper  la3’ers,  undergo  development  into  filaments  and 
fibro-cellular  tissue  ;  those  on  the  surface  are  either  thrown  off  in  a 
rudimentary  form,  or  degenerate  into  pus-cells  ;  whilst  those  at  the 
edges  become  converted  into  epithelial  scales.  Thus  we  see  the  same 
process  giving  rise  to  granulation-cells,  to  pus,  to  epithelium,  and  to 
fibro-cellular  tissue. 

The  development  of  vessels  in  granulations — a  most  wonderful  and 
beautiful  process,  b^’  which  thousands  of  vessels  may  form  in  a  day  on 
a  healthy  granulating  surface — is  identical  with  their  general  develop¬ 
ment  in  fymph,  which  will  be  described  in  Chapter  TII. :  a  series  of 
loops  and  arches  being  formed  as  outgrowths  from  neighboring  vessels. 

The  sensibility  of  granulations  varies  considerably^,  being  often  greatest 
in  those  which  spring  from  tissues  that  are  naturally  the  least  sensitive, 
as  bone  for  instance.  Xo  nerve  has  been  traced  in  granulations;  hence 
their  apparent  sensibility  would  appear  to  depend  upon  that  of  the  sub¬ 
jacent  inflamed  tissues. 

The  characters  of  granulations  afford  important  indications  to  the 
Surgeon  as  to  the  condition  of  the  surface  from  which  they  spring,  and 
the  state  of  the  patient’s  general  health.  Granulations  indicative  of  a 
healthy  local  and  constitutional  condition  are  small,  florid,  pointed, 
closely  set,  and  bathed  with  healthy'  pus  ;  the  use  of  which  appears  to  be 
to  cover  and  protect  the  tender  surface  with  a  soft  lubricant  coating,  into 
which  the  granulations  may^  sprout  w'ithout  being  dried  by'  the  air,  or 
readify  damaged  in  any  other  way. 

In  a  weak  state  of  the  sore,  or  of  the  constitution,  the  secretion  of 
pus  diminishes,  and  it  loses  its  healthy  character  ;  the  granulations 
become  large,  pale,  and  flabby',  appearing  to  be  oedematous  from  infil¬ 
tration  of  serum,  and  assuming  a  glassy  or  semitransparent  look,  with 
a  purplish  hue.  Occasionally  hemorrhage  takes  place  into  them,  and 
they  become  broken  down  and  sloughy.  If,  whilst  a  sore  is  healthily 
granulating,  morbid  action  be  set  up  in  it,  or  in  the  economy' — as  by 
the  supervention  of  erysipelas  or  fever — the  granulations  and  pus-cells 
degenerate  at  once ;  the  granulations  becoming  rapidly'  absorbed,  the 
surface  of  the  sore  assuming  a  gray'ish,  sloughy  look,  and  the  formation 
of  pus  being  arrested. 

The  Healing  Process,  or  Cicatrization,  is  that  by  which  the  ulcer 
closes  and  becomes  covered  by'  an  integumental  investment.  Two  dis¬ 
tinct  processes,  though  carried  on  simultaneously',  are  necessary  for  the 
accomplishment  of  this.  These  consist  in  the  granulations  assuming  a 
healthy  character,  and  covering  themselves  with  new  cuticle ;  and  in  the 
contraction  of  the  surface  of  the  sore. 

The  first  change  that  takes  place  in  an  ulcer  that  is  about  to  undergo 

VOL.  I. — 10 


146 


ULCERATION. 


the  healing  process,  is  that  the  granulations  become  florid,  and  are 
bathed  with  healthy  pus ;  the  edges  and  surface  of  the  sore  then  assume 
the  same  level — the  granulations  rising,  and  the  edges  subsiding.  So 
long  as  there  is  any  inequality  in  this  respect,  the  process  of  cicatrization 
cannot  go  on.  The  granulations  nearest  the  edges  become  smooth,  cease 
to  pour  out  pus,  and  are  glazed  over  with  a  thin,  whitish-blue  pellicle — 
which  is  the  first  appearance  of  new  skin — composed  of  granulation-cells 
developing  into  epithelium.  As  cicatrization  advances,  the  part  of  the 
sore  immediatel}’  inside  this  bluish-white  line  will  be  seen  to  be  occupied 
by  a  red  zone,  which,  in  the  course  of  four-and-twent}^  hours,  becomes, 
in  its  turn,  new  epithelium,  and  appears  to  be  the  link  between  granula¬ 
tion  and  true  cuticle. 

At  the  same  time  that  these  changes  are  going  on,  contraction  of  the 
sore  takes  place.  This  would  appear  to  be  entirely  a  mechanical  process, 
and  not  a  vital  action ;  it  is  owing  to  the  conversion  of  the  exudation- 
cells  of  the  granulations  into  the  filaments  of  cicatricial  tissue,  which, 
being  more  closely  packed  and  becoming  drier,  occupy  less  space  (Paget). 
This  contraction  commences  as  soon  as  the  sore  presents  a  tendency  to 
cicatrize,  and  continues  for  a  considerable  time  after  this  is  completed. 

Cicatrization  advances  with  greatest  rapidity  around  the  edges  of  the 
sore,  the  centre  taking  the  longest  time  to  heal,  in  consequence  of  the 
activit}’^  of  the  process  appearing  to  diminish  the  farther  the  new  skin 
extends  from  the  old  tissues.  Indeed,  if  the  ulcer  be  large,  there  may  not 
be  sufficient  force  for  cicatrization  of  its  centre.  A  sore  of  a  circular 
shape  usually  takes  a  longer  time  to  heal  than  an  oval  or  elongated  one. 
The  new  skin  is  formed  at  the  edge  only,  and  never  primarily  in  the 
centre  of  an  ulcer,  unless  islands  of  old  skin  be  left  there  undestroyed, 
to  serve  as  centres  of  cicatrization.  It  would  appear  to  be  necessary 
for  the  healing  process,  that  granulations  have  some  of  the  old  textures 
to  be  modelled  upon,  from  the  plastic  force  of  which  there  is  an  impulse 
given  that  causes  their  development  into  analogous  structure. 

The  changes  taking  place  in  a  cicatrix  do  not  cease  with  its  formation. 
Two  processes  continue  for  a  very  considerable  length  of  time  after¬ 
wards  :  viz.,  the  gradual  contraction  and  the  development  of  the  cicatri¬ 
cial  tissue. 

We  have  seen  that  granulations  tend  to  contract  during  the  healing 
of  an  ulcer,  and  that  the  diminution  in  surface  thus  produced  facilitates 
greatly  its  cicatrization.  Hence  a  scar  is  never  so  large  as  the  original 
sore.  This  contraction  continues,  however,  and  does  not  attain  its  maxi¬ 
mum  until  long  after  the  completion  of  cicatrization,  often  occasioning 
great  puckering  or  deformity.  The  degree  of  contraction  depends  parti}’" 
on  the  seat  of  the  scar,  but  principally  on  the  agent  that  produces  the 
ulcer;  if  the  scar  be  seated  on  a  part  where  the  skin  is  very  tense,  the 
contraction  will  be  slight ;  if  the  skin  be  naturally  loose,  it  will  be  con¬ 
siderable.  The  contraction  that  takes  place  in  scars  which  result  from 
burns  is  greater  than  those  which  occur  from  any  other  cause,  often  pro¬ 
ducing  serious  deformity  and  great  distress  to  the  patient.  These  results 
do  not  supervene  in  their  fullest  extent  until  after  a  lapse* of  some  weeks 
or  months  from  the  infliction  of  the  injury.  This  contraction  would  appear 
in  some  cases  to  be  due,  not  onl}^  to  the  consolidation  of  the  texture  of 
the  scar,  but  to  the  development  in  it  of  yellow  elastic  tissue. 

Two  great  changes  are  wrought  by  time  in  the  texture  of  a  cicatrix. 
In  the  first  place,  its  tissue  assimilates  more  and  more  to  the  normal 
structure  of  the  part;  and  secondly,  its  deep  attachments  become  more 
movable.  When  first  a  scar  is  formed,  it  is  thin,  reddish,  or  bluish  and 


DIAGNOSIS  AND  TREATMENT. 


147 


shining,  being  composed  of  imperfectly  developed  filamentous  tissues, 
covered  by  a  thin  epithelial  layer.  As  it  becomes  older,  it  assumes  a 
dead-white  color,  and  becomes  depressed,  and  gradually,  but  slowly, 
many  3'ears  being  required  for  the  change,  it  “wears  out;”  that  is  to  sa^', 
its  structure  more  closely"  resembles  that  of  the  texture  of  the  part  on 
which  it  is  seated.  It  never,  however,  becomes  developed  into  true  skin, 
as  neither  the  hair  nor  sebaceous  or  sudoriferous  glands  form  in  it. 

In  structure^  cicatrices  are  composed  of  a  fibro-cellular  tissue,  rather 
sparingl3’  supplied  with  bloodvessels,  and  covered  by  a  thin  epithelial 
covering,  usually  smooth  and  glistening,  but  sometimes  nodulated  and 
rugose. 

The  sensibility  of  the  cicatrix  itself  is  lower  than  that  of  the  skin 
generall3^,  but  the  edges  of  the  integument,  where  in  contact  with  the 
cicatrix,  are  usuall3"  more  highl3^  sensitive  than  are  the  integuments  on 
other  parts  of  the  bod3^  When  tough  and  irregular  cicatricial  bands, 
or  “  bridles,^’  stretch  across  a  part,  it  wdll  usuall3'  be  found  that  the3"  are 
devoid  of  sensibility. 

Coincidentl3^  with  these  changes,  the  scar  loosens  its  deep  attachments, 
so  that  it  can  be  moved  more  freely  upon  subjacent  parts.  It  is  a  long 
time  before  the  scar  attains  the  vitality  of  the  older  structures,  if  ever 
it  do  so  completel3’ ;  and  the  larger  it  is,  the  less  the  power  will  usually 
be.  Under  the  influence  of  scurvy  or  S3'philis,  an  old  scar  is  apt  to 
open  up  again  ;  so  also,  if  a  fresh  ulcer  be  formed  on  the  old  cicatrix,  it 
will  take  a  longer  time  to  heal  than  the  original  one. 

Diagnosis. — This  is  readily  made  when  ulcers  are  seated  on  the  skin, 
where  no  art  is  required  to  recognize  a  sore.  On  the  mucous  surfaces, 
however,  it  is  not  alwa3’s  eas3^  to  do  so ;  enlarged  follicles  and  ciypts, 
or  aphthge,  being  constantly  confounded  with  ulcers.  The  dilficult3'  here 
proceeds  from  the  circumstance  that  muco-pus  may  be  poured  out  from 
a  simpty  inflamed  surface,  or  from  one  in  which  the  abraded  epithelium 
and  open  ciypts  are  mistaken  for  ulcers. 

Treatment. — In  the  Local  Treatment  of  ulceration,  the  Surgeon 
must  be  guided  by  the  special  conditions  presented  b3^  the  ulcer,  which 
will  be  described  presentl3\  But  there  are  some  points  which  demand 
attention  in  all  cases.  1.  Inflammation,  when  present,  must  be  subdued; 
until  this  is  done,  no  proper  reparative  action  can  go  on.  2.  Congestion 
and  determination  of  blood  must  be  prevented,  b3'-  keeping  the  part  at 
rest,  and  in  such  a  position  as  will  allow  the  ready  return  of  blood  from 
it.  3.  Proper  local  applications  adapted  to  the  nature  of  the  case,  of  an 
emollient,  sedative,  astringent,  or  stimulating  character,  must  be  em- 
plo3'ed  frequently,  conjoined  with  pressure  upon,  or  support  to,  the 
weakened  vessels  of  the  part. 

Transplantation  of  Cuticle. — It  has  long  been  known  to  Plysiologists 
and  to  Surgeons,  that  portions  of  the  teguraentar3^  structures,  when 
completel3'  detached  and  transplanted  to  other  parts  of  the  surface  of 
the  bod3^,  occasionally  retain  their  vitalit3",  and  grow  on  the  surface  on 
which  the3^  have  been  inserted. 

The  experinients  of  John  Hunter  on  the  transplantation  of  teeth,  of 
the  cock’s  spur,  the  experiments  of  Aberneth3"  on  the  same  subject,  the 
adherence  and  continued  growth  of  a  freshl3"  separated  portion  of  the 
nose  or  chin,  the  transplantation,  by  Buenger,  of  a  piece  of  the  skin  of  the 
thigh  on  to  the  face  for  the  formation  of  a  new  nose,  and  the  observations 
of  Walther  that  the  button  of  bone  removed  by  a  trephine,  if  reinserted, 
will  contract  adhesions  again — all  prove  the  fact  that  freshly  separated 
parts,  if  immediately  reapplied  to  a  raw  surface,  may  contract  adhesions 


148 


ULCEEATION. 


to  it.  But  it  was  reserved  for  Beverdin  to  show  that  cuticle,  if  trans¬ 
planted,  might  be  employed  as  an  agent  in  the  cicatrization  of  granu¬ 
lating  surfaces.  This  observation  is  as  interesting  in  its  scientific  aspect, 
as  it  is  full  of  promise  in  its  application  to  plastic  surgery,  and  has 
already  been  found  in  many  instances  to  be  of  the  greatest  value  in 
facilitating  the  cicatrization  of  large  ulcerated  surfaces,  which  could  not 
be  covered  by  skin  in  any  other  wa}’.  It  has  already  been  explained 
that  the  process  of  cicatrization  of  an  ulcer  always  takes  place  from  and 
through  the  medium  of  preexistent  epidermis  ;  and  further,  that  the 
formative  force  necessary  for  the  extension  of  the  cicatrix  from  the  edge 
gradually  becomes  weakened,  and  at  last  entirely  ceases.  In  such  cases, 
especially  when  resulting  from  burns,  flaps  of  skin  have  occasionally 
been  transplanted.  But  Beverdin  has  found  that  this  is  not  necessaiy, 
and  that  all  that  is  required  is  to  plant  small  islets  of  freshly  separated 
cuticle  on  the  granulating  surface.  These  adhere  where  trajisplanted, 
and  each  islet  forms  the  centre  of  a  new  process  of  cicatrization,  which, 
spreading  from  its  edge,  and  coalescing  with  that  moulded  by  the  sur¬ 
rounding  skin,  and  by  the  neighboring  islets  of  transplantation,  soon 
covers  the  granulating  surface  with  a  healthy  cuticular  cicatrix. 

The  process  of  cuticular  transplantation  is  as  follows.  A  piece  of 
skin  on  some  sound  part  of  the  body — the  outside  of  the  arm,  for  in¬ 
stance — about  the  size  of  an  oat  or  a  split  pea,  is  pinched  up  with  a  pair 
of  forceps,  and  snipped  off  with  curved  scissors.  The  whole  thickness 
of  the  skin  need  not  be  separated,  but  merely  the  cuticle  down  to  and  in¬ 
cluding  the  papillaiy  la3’er  of  the  true  skin,  so  as  just  to  show  blood.  The 
operation,  when  properl}’  performed,  is  almost  painless.  The  little  patch 
of  separated  skin  is  now  placed,  with  the  raw  side  downwards,  on  the 
surface  of  the  ulcer,  covered  and  retained  in  position  by  a  strip  of 
isinglass  plaster.  It  is  left  undisturbed  for  about  four  da3’s,  at  the  end 
of  which  time  it  will  be  found  to  be  adherent,  and  speedil}’  becomes  the 
centre  of  a  new  process  of  cicatricial  action,  which  spreads  in  a  gradual!}" 
widening  circle,  until  it  fuses  itself  into  the  cicatricial  deposit  that  is  in 
process  of  formation  from  the  circumference  of  the  sore,  or  from  other 
transplanted  islets,  and  thus  the  cicatrix  is  rapidl}"  formed. 

For  the  success  of  this  little  operation,  it  is  necessary  that  the  granu¬ 
lating  surface  on  to  which  the  transplantation  is  made,  be  a  healthy  one ; 
that  it  be  not  the  seat  of  specific  disease  of  an}’  kind,  or  the  result  of  such 
disease;  and  that  the  process  of  cicatrization  have  commenced  at  its 
edges.  The  piece  of  transplanted  skin  should  be  tenderl}’  handled,  and 
at  once  applied  and  retained  b}"  moderate  pressure.  In  placing  it  in  its 
new  position,  it  is  well  that  the  granulations  be  not  bruised,  so  as  to  be 
made  to  bleed,  which  would  be  fatal  to  the  success  of  the  experiment. 
It  is  better  to  appl}"  several  small  grafts  of  skin  than  one  large  one ;  each 
new  graft  acting  as  a  centre  of  cicatrization,  and  the  process  going  on 
more  rapidl}’  from  several  small  centres  than  from  one  large  one. 

The  Constitutional  Treatment  must  be  carefull}’  attended  to.  Unless 
this  be  done,  the  best  regulated  local  plan  may  be  emplo3’ed  in  vain. 
Attention  to  the  digestive  organs,  and  improvement  of  the  constitution, 
if  it  be  strumous  or  S3’philitic,  will  do  more  in  these  cases  than  any  other 
means  can  accomplish.  The  nutrition  of  the  patient  requires  due  care. 
If  he  lose  weight,  an  ulcer  will  not  heal.  It  is  onl}"  when  the  nutrition 
is  capable  of  maintaining  or  increasing  the  bodily  weight,  that  the  heal¬ 
ing  process  can  be  expected  to  take  place. 

Various  Forms  of  Ulcer. — Having  given  a  general  description  of 


INDOLENT  OK  CALLOUS  ULCER. 


149 


the  process  of  ulceration  and  its  repair,  we  have  now  to  describe  the 
various  forms  in  which  ulcers  present  themselves  to  the  Surgeon. 

When  they  occur  in  the  skin,  as  the  result  of  non-specific  disease,  ulcers 
may  be  arranged  under  the  following  heads:  the  Healthy;  the  Weak; 
the  Indolent;  the  Irritable;  the  Inflamed;  the  Phagedsenic  or  Slough¬ 
ing;  the  Varicose;  and  the  Hemorrhagic.  Besides  these  varieties,  each 
of  which  is  marked  by  distinct  characteristics,  various  other  forms 
of  ulceration  depending  on  specific  causes,  as  the  Syphilitic,  Scrofulous, 
Lupoid,  Cancerous,  &c.,  are  met  with;  all  of  which  will  be  treated  under 
their  respective  chapters. 

The  varieties  presented  by  ulcers  are  by  no  means  dependent  on  local 
conditions  merely,  though  these  influence  them  greatly,  but  are  in  a 
great  measure  owing  to  constitutional  causes.  Indeed,  the  aspect  of  the 
ulcer,  and  the  character  of  its  granulations  and  of  its  discharge,  are  ex¬ 
cellent  indications  of  the  state  of  health  and  of  the  general  condition  of 
the  patient,  as  well  as  of  the  local  disease. 

Healthy  or  Purulent  Ulcer. — This  may  be  considered  the  type  of 
the  disease.  It  presents  a  circular  or  oval  surface,  slightlj’’  depressed, 
thickly  studded  with  small  granulations  exuding  laudable  pus,  and  hav¬ 
ing  a  natural  tendency  to  contract  and  heal.  It  is  the  object  of  all  our 
treatment  to  brino;  the  other  forms  of  ulcer  into  this  condition. 

Treatment. — In  the  management  of  the  healthy  ulcer,  the  treatment 
should  be  as  simple  as  possible;  water-dressing  and  the  pressure  of  a 
bandage  usually  enabling  it  readily  to  cicatrize.  Sometimes,  however, 
as  has  already  been  stated,  the  healing  process  is  retarded  or  arrested 
in  consequence  of  the  extent  of  the  ulcer.  In  such  cases,  the  trans¬ 
plantation  of  cuticle  will,  by  affording  centres  of  cicatrization,  expedite 
cure.  According  to  Lister,  the  application  of  the  antiseptic  gauze  and 
protective,  in  the  manner  described  in  speaking  of  the  treatment  of 
abscess,  has  also  been  found  most  efficacious  in  promoting  the  healing 
of  ulcers  of  long  duration.  The  strength  of  the  solution  of  carbolic  acid 
should  be  low  (about  1  in  400),  so  as  to  avoid  the  production  of  undue 
irritation. 

Weak  Ulcer  not  uncommonly  occurs  from  emollient  applications 
having  been  continued  for  too  long  a  time  in  the  last  variety  of  the 
disease ;  the  granulations  then  becoming  high  and  flabby,  with  a  semi¬ 
transparent  appearance  about  them,  and  sometimes  rising  in  large, 
exuberant  gelatinous,  reddish-looking  masses  above  the  surface  of  the 
sore.  These  high  granulations  have  a  feeble  vitality,  and  readily  slough. 

The  Treatment  of  this  form  of  ulcer  consists  in  keeping  the  part 
elevated  and  carefully  bandaged,  and  applying  an  astringent  dressing  to 
the  sore,  such  as  the  “red  wash,”  or  a  weak  solution  of  the  sulphate  of 
copper  or  of  zinc,  according  to  the  following  formula:  Sulphate  of  zinc, 
gr.  xvj ;  compound  tincture  of  lavender  and  spirits  of  rosemary  of  each 
5ij  ;  water,  oviij.  This  will  be  found  a  most  useful  application;  and 
the  granulations  may  be  touched  from  time  to  time  with  nitrate  of  silver. 

Indolent  or  Callous  Ulcer. — This  is  always  very  chronic.  It  is 
situated  upon  the  outer  side  of  the  lower  extremity,  between  the  ankle 
and  calf,  and  most  frequently  occurs  in  men  about  the  middle  period  in 
life.  It  is  deep  and  excavated,  with  a  flat  surface,  covered  by  irregular 
and  badly  formed  granulations,  exuding  a  thin  and  sanious  pus,  having 
hard,  elevated,  and  callous  edges,  and  presenting  generally  an  irregular 
and  rugged  look.  The  surrounding  integument  is  congested  and  matted 
to  the  subjacent  parts;  there  is  usually  very  little  subcutaneous  areolar 
tissue  about  it,  the  skin  being  firmly  fixed  to  the  subjacent  fascia;  and 


150 


ULCERATION. 


it  would  appear  as  if  it  were  in  consequence  of  this  want  of  a  vascular 
substratum  from  which  to  spring,  that  granulations  do  not  readily  arise. 
There  is  no  pain  attending  this  ulcer,  and  its  surface,  which  often  attains 
a  very  large  size,  may  usuall}^  be  touched  without  the  patient  feeling  it. 

Treatment. — The  principle  of  the  treatment  here  is  twofold ;  to  depress 
the  edge,  and  to  elevate  the  base  of  the  sore.  This  is  effected  by  pres¬ 
sure  and  stimulation  conjoined.  The  treatment  should  be  commenced 
b3^  rubbing  the  surface  of  the  ulcer  and  the  surrounding  congested  in¬ 
tegument  with  nitrate  of  silver;  a  linseed-meal  poultice  should  then  be 
applied  for  twenty-four  hours,  after  which  the  sore  should  be  properly 
strapped  on  the  plan  recommended  by  Baynton.  The  best  plaster  for 
this  purpose  is  the  emplastrum  saponis.  to  which  some  of  the  emplastrum 
resinae  is  added  to  make  it  sufficiently  adhesive;  this,  spread  upon 
calico,  should  be  cut  into  strips  sixteen  or  eighteen  inches  in  length, 
and  about  an  inch-and-a-half  in  width;  the  centre  of  the  strip  should 
then  be  laid  smoothly  on  the  side  of  the  limb  opposite  to  the  sore,  and  the 
ends,  being  brought  forward,  are  to  be  crossed  obliquely  over  it.  Strip 
after  strip  must  be  applied  in  this  wa}’-,  until  the  limb  is  covered  for  a 
distance  of  a  couple  of  inches  above  and  below  the  ulcer.  If  the  sore  be 
near  the  ankle,  this  joint  should  be  included  in  the  strapping.  Each 
strip  of  plaster  should  be  applied  with  an  equal  degree  of  pressure, 
which  may  often  be  considerable,  and  it  should  cover  at  least  one-third 
of  the  preceding  strap  ;  the  limb  must  then  be  carefully  bandaged  from 
the  toes  to  the  knee.  Under  this  plan  of  treatment,  the  edges  will  sub¬ 
side,  the  surface  of  the  sore  will  become  florid,  and  granulations  yielding 
abundant  discharge  will  speedily'  spring  up.  Much  of  its  success  will 
depend  upon  the  close  attention  that  is  paid  to  the  case.  If  the  skin  be 
irritable,  no  resin-plaster  should  be  used,  but  merel}'  the  soap  or  lead; 
and  the  plasters  should  be  changed  at  least  every  fort3’'-eight  hours.  If 
the  discharge  be  veiy  abundant,  small  holes  should  be  cut  in  the  strips 
to  allow  it  to  escape.  When  by  this  plan  of  treatment  the  edges  of  the 
sore  have  been  brought  down,  and  the  granulations  sufficient!}^  stimu¬ 
lated,  an  astringent  lotion  with  bandaging  ma}’’  advantageous!}^  be  sub¬ 
stituted  for  the  plasters.  In  some  of  these  cases  I  have  found  benefit 
from  the  internal  administration  of  liquor  arsenicalis. 

Irritable  Ulcer  is  mostly  met  with  in  women  about  the  middle 
period  of  life,  especially  in  those  of  a  nervous  and  bilious  temperament. 
It  is  usually  of  small  size,  and  situated  about  the  ankles,  or  upon  the 
shin.  Its  edges  are  irregular,  but  not  elevated  ;  the  surface  is  grayish, 
covered  with  a  thin  slough,  and  secreting  unhealthy  sanious  pus.  Its 
principal  characteristic  is  the  excessive  pain  accompanying  it,  which 
often,  by  preventing  sleep,  disturbs  seriously  the  general  health. 

In  the  Treatment  of  this  ulcer,  we  must  attend  to  the  constitutional 
as  well  as  to  the  local  condition.  The  patient  should  be  put  upon  an 
alterative  course  of  medicine,  wuth  aloetic  purgatives,  and  some  sedative 
at  bedtime  to  procure  rest.  The  mode  of  topical  medication  which  I 
have  found  to  succeed  best,  is  to  brush  the  surface  of  the  sore  and  the 
surrounding  parts  from  time  to  time  with  a  strong  solution  of  nitrate  of 
silver,  and  then  to  keep  emollient  and  sedative  applications  applied  to 
it,  such  as  lead  and  opium  lotions.  The  occasional  application  of  the 
nitrate  of  silver  deadens  materially  the  morbid  sensibility  of  the  sore, 
and  assists  its  orranulation. 

Inflamed  Ulcer. — This  is  characterized  by  much  redness,  heat,  and 
swelling  of  the  surrounding  parts,  with  a  thick  and  offensive  discharge. 


VARICOSE  ULCER. 


151 


often  streaked  with  blood  ;  it  may  arise  from  the  over-stimulation  of  one 
of  the  other  varieties. 

The  Treatment  must  be  locally  and  generally  antiphlogistic.  The 
elevated  position,  the  application  of  leeches  around  the  sore,  and  of  cold 
evaporating  lotions  to  the  surface  of  the  limb,  speedily  subdue  the 
inflammatory  action  ;  and  the  healing  process  then  takes  place  with  great 
rapidity. 

Sloughing  Ulcer. — When  not  specific,  this  is  an  increased  degree 
of  the  inflamed  variety,  usually  occurring  in  a  feeble  or  cachectic  consti¬ 
tution,  and  generally  accompanied  by  a  good  deal  of  irritative  fever. 
An  angry  dusky  red  blush  forms  about  the  sore,  which  becomes  hot  and 
painful ;  the  surface  assumes  a  grayish  sloughy  look,  the  edges  are  sharp 
cut,  and  the  ulcerative  action  extends  rapidly. 

Treatment. — This  should  consist  in  improving  the  general  health  by 
lessening  irritation,  and  keeping  up  tone.  The  administration  of  opiates, 
with  nourishing  but  unstimulating  diet,  should  be  trusted  to,  at  the 
same  time  that  the  local  action  is  subdued  by  rest  and  warm  opiate 
lotions.  When  the  inflammatory  condition  has  subsided,  tonics  should 
be  given  internally,  and  a  grain  or  two  of  the  sulphate  of  copper  or  of 
zinc,  or  a  little  carbolic  acid,  may  be  added  to  the  lotion  with  which  the 
sore  is  dressed. 

The  specific  varieties  of  sloughing  ulcer  will  be  considered  in  the  Chap¬ 
ters  on  Hospital  Gangrene,  etc. 

Varicose  Ulcer  derives  its  chief  characteristic  from  being  compli¬ 
cated  with  or  dependent  upon  a  varicose  condition  of  the  veins  of  the 
leg.  In  this  affection  of  the  venous  trunks  the  skin  graduallj’’  undergoes 
degeneration,  becoming  brawny,  of  a  purplish-brown  color,  and  being 
traversed  in  all  directions  by  enlarged  and  tortuous  cutaneous  veins. 
The  ulcer  forms  at  one  of  these  congested  spots,  by  the  breaking  down 
of  the  already  disorganized  and  softened  tissue,  forming  a  small  irregular 
chasm  of  an  unhealthy  appearance,  and  varying  much  in  character,  being 
sometimes  inflamed,  at  others  irritable  or  sloughy,  and  then  becoming 
indolent.  One  of  the  most  serious  effects  of  this  ulcer  is  that,  by  pene¬ 
trating  into  one  of  the  dilated  veins,  it  occasionally  gives  rise  to  very 
abundant  hemorrhage ;  the  patient  in  the  course  of  a  few  seconds  losing 
a  pint  or  two  of  blood.  This  hemorrhage  may  be  readily  arrested  by 
laying  the  patient  on  his  back,  elevating  the  limb,  and  compressing  the 
bleeding  point  with  a  pledget  of  lint  and  a  roller. 

The  Treatment  of  a  varicose  ulcer  must  have  special  reference  to  the 
condition  of  the  veins  that  occasions  it;  no  local  applications  having 
much  effect  unless  the  pressure  of  the  column  of  blood  in  the  dilated 
vessels  be  taken  off  the  part.  This  may  be  done  by  means  of  a  well- 
applied  bandage,  made  of  elastic  material,  or  a  laced  or  elastic  stocking 
applied  to  the  leg,  so  as  to  keep  up  uniform  pressure  upon  the  distended 
vessels.  In  some  cases,  the  length  of  the  column  of  blood  may  be 
broken  by  the  application  of  a  vulcanized  India-rubber  band  below  the 
knee.  In  many  cases,  the  cicatrization  of  the  ulcer  cannot  be  brought 
about  in  this  way  ;  or,  if  it  heal,  it  will  constantly  break  open  again : 
or  hemorrhage  may  have  occurred  from  a  ruptured  vein  upon  its  sur¬ 
face :  means,  which  will  be  described  in  a  future  chapter,  must  then  be 
taken  for  the  permanent  occlusion  of  the  varicose  vessels.  As  this 
procedure,  however,  is  attended  by  some  danger  from  the  occasional 
induction  of  phlebitis  or  eiysipelas,  it  should  not  be  had  recourse  to 
unless  the  existence  of  one  or  other  of  the  conditions  just  mentioned 
urgently  calls  for  it. 


152 


THE  PROCESS  OF  REPAIR. 


Hemorrhagic  Ulcer — This  is  a  dark,  purplish-looking  sore,  occur¬ 
ring  in  women  suffering  from  amenorrhoea,  and  having  a  special  ten¬ 
dency,  whence  its  name,  to  ooze  blood  about  the  menstrual  periods.  It 
usually  partakes  of  the  character  of  the  irritable  ulcer. 

Treatment. — The  hemorrhagic  ulcer  requires  to  be  treated  by  consti¬ 
tutional  means,  having  for  their  object  the  improvement  of  the  patient’s 
general  health  ;  with  this  view,  the  preparations  of  iron  and  of  aloes  are 
especially  useful. 

Ulcers  on  Mucous  Membranes. — Yarious  forms  of  ulcer  occur 
upon  the  mucous  membrane  of  the  throat,  rectum,  and  genital  organs. 
As  these,  however,  are  commonly  specific,  they  will  be  hereafter  de¬ 
scribed. 

When  ulcers  of  the  mucous  membrane  are  not  of  a  specific  character 
they  present  the  general  appearances  characteristic  of  the  cutaneous 
healthy,  inflamed,  or  weak  varieties,  and  require  the  topical  applications 
which  have  been  described  as  suited  to  these  conditions  ;  though  gener¬ 
ally  they  will  demand  the  free  employment  of  caustics,  especially  of  the 
nitrate  of  silver. 


CHAPTER  YII. 

THE  PROCESS  OF  REPAIR. 

Having,  in  the  preceding  three  Chapters,  described  certain  patholo¬ 
gical  conditions  in  which  interference  with  the  normal  nutrition  of  the 
part  is  a  prominent  feature,  and  having,  in  regard  to  one  of  these,  indi¬ 
cated  the  means  b}'’  which  Nature  repairs  the  injury,  we  have  now  to 
give  a  summary  of  the  means  by  which  injuries  in  general  are  repaired. 
Surgical  operations  are  generally  attended  with  the  production  of  wounds, 
which  difler  in  no  essential  respects  from  the  incised  wounds  to  be 
described  in  Chapter  IX. ;  and  the  description  of  the  various  forms  of 
the  healing  process,  to  be  now  given,  will  be  equally  applicable  to  the 
results  of  the  use  of  the  Surgeon’s  knife  and  to  those  arising  from 
accident. 

A  wound,  or  solution  of  continuity,  may  unite  in  one  of  the  following 
five  ways :  1,  by  the  direct  Growing  Together  of  two  Opposed  Surfaces  ; 
2,  by  Scabbing ;  3,  by  the  opposed  surfaces  uniting  through  the  medium 
of  Coagulable  Lymph — union  by  Adhesive  Inflammation;  4,  by  Granu¬ 
lations  springing  up  from  the  sides  and  bottom,  and  covering  themselves 
with  an  epithelial  layer  ;  and  5,  by  the  Growing  Together  of  two  Granu¬ 
lating  Surfaces.  The  first  three  methods  of  repair  are  confined  in  their 
action  to  incised  and  punctured  wounds,  the  first  being  special  to  clean 
incisions.  The  last  two  may  occur  in  incised  wounds,  if  either  of  the 
three  preceding  ones  fail,  and  are  the  only  means  by  wliich  contused  and 
lacerated  wounds,  with  some  rare  exceptions,  have  been  known  to  heal. 

I.  The  Direct  Growing  Together  of  Opposite  Surfaces  was 
termed  by  Hunter  Union  by  the  First  Intention  though  the  latter 
term  is  not  employed  in  this  acceptation  by  modern  Surgeons,  most  of 
whom  extend  it  to  the  union  by  adhesive  inflammation.  Wounds  that 
unite  in  this  way  do  so  by  the  simple  and  direct  coalescence  of  the  op¬ 
posed  surfaces  ;  and  not,  as  Hunter  had  supposed,  by  the  interposition 


HEALING  BY  SCABBING  OR  INCRUSTATION. 


153 


of  a  layer  of  effused  blood  becoming  the  bond  of  union ;  or,  as  others 
have  imagined,  by  l3miph  poured  out  to  form  an  uniting  medium. 
Macartney  pointed  out  the  error  of  these  doctrines,  and  showed  that  the 
process  consisted  essentially'  in  clean-cut  parts,  laid  in  apposition,  uniting 
and  growing  together  directly  in  the  course  of  a  few  hours,  without 
inflammation  or  any’-  of  its  products  being  required  to  effect  the  union ; 
hence  he  termed  it  “  immediate  union.''’’ 

The  Conditions  necessary  for  direct  union  are  tlie  following :  1.  A 
healthy  constitution  ;  2.  The  perfect  coaptation  of  the  cut  surfaces ;  3. 
The  exclusion  of  air  and  foreign  bodies  from  between  the  sides  of  the 
wound ;  4.  The  absence  of  all  inflammatory  action  ;  and  5.  A  certain 
homogeneity  of  structure.  As  may’’  readily^  be  supposed,  it  is  not  often 
in  surgical  practice  that  such  a  simple  and  direct  result  can  be  obtained; 
though,  in  some  of  the  plastic  operations  about  the  face,  we  succeed  in 
securing  it.  It  is  especially  in  children  and  y'Oung  people,  in  whom  the 
constitution  is  pure  and  healthy^,  that  this  kind  of  union  is  to  be  obtaind, 
and  after  operations  for  the  cure  of  deformities,  as  hare-lip  or  cleft  palate, 
rather  than  in  those  for  the  removal  of  disease.  After  some  of  the 
larger  operations,  in  adults  even,  this  kind  of  union  may’’  exceptionally 
take  place.  Thus  Paget  records  a  case  of  amputation  of  the  breast,  in 
which  the  flaps  contracted  immediate  and  direct  union  with  the  subjacent 
IDarts ;  and,  on  the  patient  dying  of  erysipelas  at  the  end  of  three  weeks, 
the  union  was  so  perfect  that  it  was  impossible  to  discover  by^  micro¬ 
scopic  examination  that  any’’  inflammation  had  existed,  or  exudative 
matter  had  been  poured  out.  In  some  flap  operations,  the  Surgeon  may 
be  successful  in  attaining  union  by  this  means.  Thus,  in  amputations 
of  the  thigh  and  arm,  we  occasionally  find  that  nearly^  the  whole,  or  a  con¬ 
siderable  portion  of  the  flaps  are  united  together  at  the  expiration  of 
about  eight-and-forty  hours. 

Homogeneity  of  Structure  IS  of  essential  importance  in  securing  this 
kind  of  union.  It  cannot  take  place,  for  instance,  between  a  muscular 
flap  and  the  cut  end  of  the  bone.  But  it  takes  place  here  between  the 
soft  parts  corresponding  in  structure;  and  the  more  homogeneous  this 
is,  the  more  likely  is  union  to  occur.  Hence  it  is  especially  easy^  to 
secure  it  in  wounds  of  the  face ;  composed  as  this  region  is  of  integu- 
mental  structure,  and  cellulo-adipose  and  muscular  tissues,  nearly'-  uni¬ 
formly  blended. 

The  advantages  to  be  gained  by  this  mode  of  union  are,  absence  of 
inflammatory  action,  conservation  of  the  vital  force,  and  immediate  and 
permanent  closure  of  the  cavity*  of  the  wound,  rendering  the  patient  less 
liable  to  the  after-consequences  that  attend  the  healing  of  open  wounds. 
Further,  there  is  no  development  of  cicatricial  tissue,  and  consequently 
no  danger  of  subsequent  contraction  and  deformity. 

2.  Healing  by  Scabbing  or  Incrustation  consists  in  the  direct 
adhesion  of  the  lower  part  and  sides  of  a  wound  under  a  crust  of  dried 
blood,  serum,  hair,  etc.,  which  forms  an  air-tight  covering.  The  absence 
of  inflammation  is  necessary*  for  healing  by  scabbing;  for,  if  any*  effusion, 
occur,  the  crust  will  be  loosened,  air  will  be  admitted  to  the  wound,  and 
all  chance  of  immediate  union  destroyed.  Hence  this  kind  of  union  is 
extremely*  rare  in  man,  except  in  small  and  superficial  injuries,  owing  to 
the  readiness  with  which  inflammation  is  set  up;  but  it  is  common  in  the 
lower  animals.  This  natural  process  is  sometimes  imitated  by^  the 
Surgeon  when  he  closes  a  small  punctured  external  wound,  such  as  that 
of  a  compound  fracture,  with  a  piece  of  lint  dipped  in  blood,  collodion, 
styptic  colloid,  friars’  balsam,  etc.,  under  which  union  takes  place.  The 


154 


THE  PROCESS  OF  REPAIR. 


essential  point  in  obtaining  union  by  scabbing  is  to  secure  the  absence 
of  air  from  the  wound,  as  well  as  any  foreign  body  that  might  give  rise, 
by  irritation,  to  inflammatory  action. 

Analogous  to  healing  b}’-  scabbing  is  the  process  of  cure  in  subcuta¬ 
neous  wounds,  as  in  dislocations,  simple  fractures,  and  other  similar 
injuries  ;  so  also  in  the  various  operations  of  tenotomy.  In  these  cases 
repair  takes  place  without  any  inflammation,  even  though  this  be  excited, 
as  it  sometimes  is,  by  the  injury;  the  reparative  material, ‘Aiucleated 
blastema,”  not  being  an  inflammatory  product. 

3.  Union  by  Adhesive  Inflammation,  the  ‘‘  Union  by  the  First 
Intention’’’’  of  modern  Surgeons,  or  Primary  Adhesion as  it  is  termed  by 
Paget,  is  effected  by  the  effusion  of  lymph  between  the  opposed  surfaces, 
and  is  more  frequently  obtained  than  the  direct  union.  In  order  that  it 
should  take  place,  the  following  conditions  are  necessary:  1.  That  the 
patient’s  constitution  be  in  a  healthy  state ;  2.  That  the  wound  be  closed, 
its  sides  brought  into  accurate  apposition,  and  the  air  excluded ;  3.  That 
the  interposition  of  all  foreign  bodies  be  carefully  guarded  against ;  4. 
That  the  inflammation  be  restrained  within  such  bounds  as  suffice  for  the 
production  of  lymph,  but  are  insufficient  for  the  destruction  and  degene¬ 
ration  of  the  latter,  or  the  production  of  pus. 

The  lymph,  or  matter  effused,  presents  itself  to  the  Surgeon  in  two 
forms.  One  is  the  true  healthy  coagulable  l3"mph — the  plastic  lymph 
of  Williams,  or  the  fibrinous  of  Paget ;  it  is  this  by  which  union  is 
eflfected.  The  other  form  has  been  named  aplastic  b^’’  Williams,  croupous 
b}^  Rokitansk}’,  and  corpuscular  b^"  Paget.  This  varietj^  of  l^unph  is 
met  with  in,  and  is  indicative  of,  cachectic  states  of  the  s^^stem.  It  con¬ 
sists  of  a  thin,  clear,  serous  fluid,  in  which  float  corpuscles,  resembling 
in  general  characters  the  white  corpuscles  of  the  blood.  The  corpuscles 
of  this  aplastic  ljunph  are  liable  to  degenerate  into  granule-cells,  granular 
matter,  and  debris.  Indeed,  this  corpuscular  lymph  is  closely  allied  to 
pus.  (See  page  125.) 

Tliese  two  primaiy  forms  of  Ij’mph,  the  fibrinous  and  the  corpuscular, 
are  almost  alwa3^s  found  together,  but  existing  in  various  proportions  in 
the  same  exudation-mass ;  the  relative  quantit3^  of  the  one  or  the  other 
element  determining  whether  it  shall  undergo  development  or  degenera¬ 
tion.  Paget  observes  that,  “  the  larger  the  proportion  of  fibrine  in  any 
specimen  of  inflammatoiy  l3unph  (provided  it  be  healthy  fibrine),  the 
greater  is  the  likelihood  of  its  being  organized  into  tissue ;  ”  this  pre¬ 
ponderance  of  fibrine  being  indicative  of  adhesive  inflammation.  And 
“  the  larger  the  proportion  of  corpuscles,  the  greater  the  probabilit3"  of 
suppuration  or  of  some  other  degenerative  process  the  preponderance 
of  corpuscles  being  a  general  feature  of  suppurative  inflammation. 

The  following  are  the  steps  in  the  process  of  union  by  adhesive  inflam¬ 
mation  in  an  ordinaiy  incised  wound.  On  the  cessation  of  all  hemor¬ 
rhage,  the  mouths  of  the  divided  vessels  and  capillaries  are  clogged  by 
red  corpuscles,  whilst  the  liquor  sanguinis  is  poured  out  over  the 
denuded  surfaces,  the  fibrine  contained  in  which,  together  with  a  large 
proportion  of  white  corpuscles,  coagulates,  leaving  the  serum  to  drain 
awa3'.  The  sides  of  the  wound  having  thus  become  “  glazed  ”  are 
approximated,  when  the  la3"er  of  fibrine,  being  continuall3^  added  to  by 
fresh  exudation,  glues  them  together ;  the  edges  of  the  external  incision 
become  slightl3''  reddened,  swollen,  and  tender  ;  the  serum,  stained  some¬ 
what  b3'  admixture  with  blood,  continues  to  exude  for  some  hours. 
Meanwhile,  permanent  union  takes  place  b3^  the  immediate  organization 
of  the  la3’er  of  fibrine  into  connective  tissue,  and  all  signs  of  inflamma- 


UNION  BY  ADHESIVE  INFLAMMATION. 


155 


tion  subside,  as  the  external  line  of  incision  becomes  graduall}-  covered 
with  epithelium.  The  adhesive  layer  forms  with  varying  rapidity  on 
different  surfaces;  thus  in  a  stump,  after  amputation,  it  will  be  found 
that  the  muscles,  fasciae,  and  areolar  tissue  are  covered  with  fibrine  in 
the  course  of  a  few'  hours ;  it  is  not  until  the  third  or  fourth  da}'  that 
the  subcutaneous  fat  becomes  coated  in  the  same  way;  and  eight  or  ten 
days  elapse  before  the  adhesive  ljunph  is  thrown  out  upon  the  cut  sur¬ 
face  of  the  bone;  and  here  it  shows  itself  first  on  the  medullary  canal, 
afterwards  on  the  cancellous  texture,  and  lastly  upon  the  hard  bone. 
For  the  production  and  organization  of  this  lymph  a  certain  amount  of 
inflammation  is  a  necessary  condition,  but,  as  before  said,  it  must  be 
confined  within  proper  limits;  an  inflammation  that  is  too  intense  or  too 
prolonged  is  fatal  to  the  adhesive  process.  If  too  violent,  the  adhesive 
stage  w'ill  be  hurried  into  the  suppurative;  whilst,  if  it  be  too  long  con¬ 
tinued,  the  development  of  the  lymph  will  be  interfered  with ;  for, 
although  inflammation  is  necessary  for  the  formation  of  the  bond  of 
union,  none  is  required  for  its  organization,  or  for  its  ultimate  develop¬ 
ment  into  fibro-areolar  tissue. 

From  what  has  been  stated  above,  it  is  clear  that  no  blood  must  be 
permitted  to  remain  betw'een  the  opposed  surfaces  w^hen  brought  into 
contact  with  a  view  to  their  adhesion  ;  it  would  simply  act  as  an  impedi¬ 
ment  to  the  coalescence  of  the  fibrinous  la3'ers.  Moreover,  it  will 
eventually  break  dowm,  and  disintegrate  in  the  suppurative  discharges 
excited  by  its  presence ;  hence  in  the  dressing  of  surgical  wounds,  such 
as  stumps  after  amputation,  and  in  all  cases  in  which  it  is  advisable  to 
attempt  to  procure  union  b\'  adhesive  inflammation,  the  cut  surfaces 
should  not  be  brought  together  for  a  few  hours,  until  all  oozing  of  blood 
has  ceased  and  the  fibrinous  laver  has  been  thrown  out. 

Vascularization  of  Lymph. — In  Ij'mph  that  undergoes  development, 
bloodvessels  are  seen  to  make  their  appearance  at  an  early  period.  With 
regard  to  the  precise  time  of  their  formation,  Dupuj’tren  and  Yillerme 
state,  from  their  experiments  on  dogs,  that  twent3'-one  da3'S  are  required  ; 
and  Travers,  from  his  experiments  on  the  frog’s  w'eb,  fixed  the  same 
period  as  that  in  w'hich  red  blood  begins  to  pass.  In  the  human  subject, 
how'ever,  the  13'mph  on  the  surface  of  an  ulcer  or  wound  certainly  appears 
to  become  vascular  long  before  this. 

How  are  the  new  vessels  formed  ? — b}'  development  in  the  l3^mph  ?  or 
by  extension  from  surrounding  parts  ?  Hunter  and  Rokitansk}'  incline 
to  the  former  opinion.  Travers  and  Quekett,  w'ho  investigated  the  matter 
full}',  believed  that  the  vessels  are  always  projected  into  the  13'mph  from 
neighboring  parts  ;  and  Paget  agrees  with  these  observers.  Travers 
states  distinctl}',  as  the  result  of  his  observations,  which  are  borne  out 
b}'  the  results  of  the  experiments  of  Tod,  that  “  there  is  no  such  thing 
as  independent  Amscularization  ;  the  whole  business  of  organization  is 
of  and  from  the  margin  of  the  w'ound.” 

According  to  Travers,  the  following  are  the  periods  of  development 
of  vessels  in  a  frog’s  web  which  has  been  wounded. 

Up  to  the  fourteenth  da}^  there  is  stasis  of  blood  in  the  vessels 
adjoining  the  wound.  From  the  fourteenth  to  the  twenty-first  day, 
channels  are  opened  in  the  plastic  matter,  at  first  colorless,  then  admit¬ 
ting  single  blood-corpuscles  ;  from  the  twent3'-first  to  the  twent3'-eighth 
da}',  the  circulation  is  more  active,  the  vessels  enlarging  and  anasto¬ 
mosing;  ill  the  fifth  week,  transparent  capillaries  pass  across  from  the 
colored  arteries  to  the  veins ;  and  in  the  sixth  week,  there  is  the  forma¬ 
tion  of  new  vessels  in  loops,  half-circles,  etc. 


156 


THE  PROCESS  OF  REPAIR. 


The  steps  by  which  this  interesting  process  is  accomplished  are  the 
following.  At  first,  small  lateral  dilatations  or  pouches  appear  at  some 
points  on  the  walls  of  the  nearest  old  vessels ;  these  grow  out  into  the 
plastic  mass,  bend  towards  each  other,  coalesce,  and  form  loops  or  forks. 
These  loops  give  rise  to  secondary  vascular  outgrowths ;  and  thus  the 
vascularization  of  the  lymph  is  completed. 

Travers  states  that  these  vessels  are  visible,  like  fine  striae,  before  the 
circulation  can  be  detected  in  them.  A  single  blood-corpuscle  first 
enters ;  this  is  followed  by  others,  which  for  some  time  have  a  see-saw 
or  oscillatory  motion,  progressing  gradually  towards  the  nearest  vessel ; 
by  the  entrance  of  the  blood  into  which  the  circulation  is  completed,  and 
becomes  continuous  and  equable. 

Degeneration  of  Lymph. — This  has  been  especially  studied  by  Paget. 
He  observes  that  it  may  wither  and  harden,  forming  dry  horny  masses 
or  vegetations  ;  that  it  may  undergo  fatty  degeneration,  and  become 
converted  into  granular  matter.  These  last  two  forms  of  degeneration 
are  frequently  met  with  in  the  coats  of  diseased  arteries.  Besides  these 
changes,  it  may  calcify,  being  replaced  by  an  inorganic  earthy  material; 
it  may  undergo  pigmentaiy  changes ;  or  it  may  be  converted  into  pus. 

4.  Granulation. — In  those  cases  in  which  union  by  direct  cohesion, 
or  by  adhesive  infiammation,  fails  to  be  accomplished,  either  from  the 
nature  and  situation  of  the  wound,  or  in  consequence  of  the  broken  state 
of  the  patient’s  constitution,  local  interference  with  the  healing  process 
or  other  disturbing  cause,  union  by  “  the  Second  Intention^  as  it  is 
termed,  occurs ;  and  we  may  often  see  in  the  same  wound,  one  portion 
healed  hy  direct  union,  another  part  b}^  adhesive  inflammation,  and  the 
remainder  by  granulation.  In  such  instances,  the  layer  of  13’mph  effused 
over  the  surface  of  the  wound  increases  until  it  is  organized  into  a 
mass  of  thick  and  ruddy  granulations,  whilst  the  serous  oozing,  in  the 
outset  transparent  and  thin,  gradually  becomes  thick  and  opaque,  and 
will  be  found  by  the  third  or  fourth  day  to  have  assumed  the  form  of 
pus.  The  inflammation  has  passed  therefore  from  the  adhesive  to  the 
suppurative  stage.  This  transition  is  attended  by  a  general  febrile  con¬ 
dition  whose  presence  is  readily"  detected  by  the  thermometer,  which 
may  indicate  a  rise  of  2°,  3°,  or  even  6°  Fahr.  With  the  establishment 
of  suppuration,  the  pyrexia  rapidl}^  abates,  and  disappears  b}^  the  fifth 
or  sixth  days  ;  any  rise  of  temperature  subsequent  to  this  date  cannot  be 
due  to  the  natural  process  of  repair,  but  denotes  danger  from  some 
other  quarter.  In  other  respects,  healing  by  granulation  is  identical 
with  the  process  of  the  repair  of  ulcers ;  and  to  the  description  of  this 
(p.  144)  the  reader  is  referred.  It  must  not  be  forgotten,  however,  that 
suppuration  is  by  no  means  essential  to  repair  b}"  granulation.  We  shall 
find  that,  under  certain  favorable  conditions,  the  repair  of  extensive  and 
severe  wounds  has  been  accomplished  with  little  or  no  formation  of  pus, 
the  organization  of  the  lymph  into  fibro-cellular  tissue  being  effected  in 
a  manner  somewhat  similar  to  that  which  obtains  in  subcutaneous  inju¬ 
ries,  such  as  simple  fractures. 

The  class  of  injuries  in  which  we  look  for  union  by  the  second  inten¬ 
tion  includes  the  contused  and  lacerated  wounds  of  all  kinds,  the  cavities 
left  after  removal  of  dead  bone,  the  raw  surfaces  following  burns  and 
scalds,  poisoned  wounds,  and  those  incised  wounds  which  have  failed  to 
heal  b}^  adhesive  inflammation,  either  from  the  state  of  the  patient’s 
health,  from  too  violent  or  too  prolonged  inflammation,  from  the  interpo¬ 
sition  of  blood  or  other  foreign  bodjq  or  from  access  of  air  to  the  wound. 


HEALING  PROCESS. 


157 


5.  Union  of  Granulating  Surfaces. — It  not  imfreqiienth'  happens 
that,  although  granulations  spring  up  over  the  sides  of  a  wound,  union 
between  the  opposed  surfaces  does  not  take  place.  We  endeavor  to 
accomplish  this  b}'  bringing  the  granulating  sides  together  and  retaining 
them  in  that  position,  when  thej-  will  cohere;  this  constitutes  union  by 
secondary  adhesion^  In  some  amputations,  and  in  many  plastic 
operations,  cases  of  hare-lip,  cleft-palate,  &c.,  union  is  occasionally 
broimht  about  in  this  fashion. 

On  considering  the  five  methods  of  union  in  wounds  just  described,  it 
is  at  once  evident  that  the  Surgeon’s  best  endeavors  should  be  directed 
towards  procuring  healing  by  one  of  the  three  first  in  preference  to  the 
two  last,  wherever  practicable.  The  patient  is  not  only  spared  the 
drain  of  a  more  or  less  prolonged  suppuration,  with  its  attendant  waste 
of  new  tissue  elements,  elaborated  at  the  expense  of  his  vital  powers, 
but  he  is  also  saved  from  the  subsequent  dangers  to  life  that  must  alwa^'S 
be  associated  with  an  open  wound.  It  has  been  remarked  above,  and 
insisted  on  veiy  strongl}',  that  access  of  air  to  the  denuded  tissues,  or 
the  presence  of  a  foreign  body  between  the  lips  of  the  wound,  are 
equally  fatal  to  direct  union,  to  union  by  scabbing,  and  to  union  by 
adhesive  infiammation. 

Circumstances  affecting  the  Healing  Process. — When  any 
animal  fiuid,  such  as  blood,  serum,  pus,  (tc.,  is  exposed  to  ordinary 
atmospheric  air,  a  putrefactive  action  is  set  up,  with  the  production  of 
various  organic  acids  of  caustic  nature,  quite  capable,  if  allowed  to 
remain  in  contact  with  a  raw  surface,  of  being  equall3'  as  irritant  as  ain^ 
extraneous  bod}'.  This  propert}'  was  formerl}'  considered  to  be  due  to 
the  action  of  oxj’gen;  but,  according  to  Pasteur  and  his  followers,  it 
arises  from  the  presence  in  the  atmosphere  of  minute  organic  parti¬ 
cles,  the  germs  of  various  monads,  bacteria,  &c.,  the  development  of 
which  in  appropriate  menstrua  is  attended  with  a  catal3'tic  or  fermenta¬ 
tive  change  in  the  chemical  constitution  of  the  fiuid.  The  supporters  of 
the  “  germ  theoiy”  state  that  it  has  been  proved  b}'  numerous  experi¬ 
ments  performed  b}'  Pasteur,  and  reported  in  the  Comptes  Hendus  of 
the  Academ}'  of  Sciences,  and  that  it  is  further  corroborated  b}'  such 
facts  as  that  pointed  out  b}'  Lister — viz.,  that  in  surgical  practice,  when 
extravasation  of  blood  and  air  into  the  cavit}'  of  the  pleura  follows 
puncture  of  the  lung  b}'  a  fragment  of  a  broken  rib,  although  the  air 
obtains  free  access  to  the  cavit}'  of  the  pleura,  no  decomposition  of  blood 
or  resulting  suppuration  need  take  place,  owing  to  the  air  having  been 
filtered  and  freed  from  the  organic  molecules  b}'  its  passage  through  the 
bronchial  tubes,  air-cells,  and  pulmonaiy  tissue. 

The  chief  point  in  the  management  of  wounds  being  to  obtain  union 
with  the  minimum  of  suppuration,  modern  Surgeons  have  endeavored  to 
prevent  or  annihilate  the  decomposition  of  the  fluids  of  the  part  in  one 
of  two  wa3's — either  by  totall}'  excluding  air  from  the  wound,  or  b}^  the 
use  of  chemical  agents  which  can  act  on  the  organic  matters  suspended 
in  the  air,  to  purify  it  and  deprive  it  of  some  of  its  catal3'tic  power. 
The  first  indication  is  followed  out  in  the  plan  of  treating  wounds  by 
hermetic  sealing,  b}^  careful  and  accurate  coaptation,  b}^  the  use  of  collo¬ 
dion,  st3'ptic  colloid,  or  lint  soaked  in  blood  to  form  an  imper'V'ious 
covering,  and  b}'  the  pneumatic  aspiration  apparatus  of  Maisonneuve ; 
the  second  by  the  use  of  antiseptics  and  disinfectants,  such  as  carbolic 
and  sulphurous  acids,  the  chlorides  of  zinc  and  iron,  compound  tincture 
of  benzoin,  spirituous  and  ethereal  solutions,  h3'drated  chloride  of  alumi¬ 
nium,  &c. 


158 


THE  PROCESS  OF  REPAIR. 


There  are  other  circumstances,  apart  from  the  local  conditions  with 
which  we  have  hitherto  dealt,  that  are  not  without  influence  on  the  pro¬ 
cesses  of  repair  in  wounds:  the  age,  temperament,  previous  state  of 
health  and  constitution  of  the  patient,  his  occupation  and  usual  mode  of 
life,  the  situation  in  which  he  is  placed  after  the  receipt  of  the  injury, 
and  many  other  matters,  must  all  more  or  less  affect  the  result.  Those 
states  of  the  system,  for  instance,  in  which  there  is  a  tendency  to  the 
formation  of  corpuscular  13’mph,  or  to  suppurative  inflammation,  such  as 
the  scrofulous  or  scorbutic  diatheses,  anndoid  degeneration  of  the  liver, 
disease  of  the  kidneys,  &c.,  must  alwa^’s  militate  against  rapidity  and 
perfection  of  cure.  Habits  of  intemperance  and  over-indulgence,  priva¬ 
tion,  exposure,  bad  sanitary  and  hygienic  conditions,  are  similarlj"  all 
antagonistic  to  reparative  action.  These  are  points  to  which  the  Sur¬ 
geon’s  attention  must  be  directed,  with  the  view  of  counteractino^  them 
as  far  as  lies  in  his  power  bj^  appropriate  precautions  and  treatment. 


DIVISION  SECOND. 

SURGICAL  INJURIES. 


INJURIES  AFFECTING  THE  TISSUES  GENERALLY. 


CHAPTER  VIII. 

CONSTITUTIONAL  EFFECTS  OF  INJURY. 

An  injury,  if  at  all  severe,  besides  its  local  consequences,  is  liable  to 
be  attended  by  certain  constitutional  effects,  some  of  which  appear 
immediately,  and  others  after  varying  intervals  of  time. 

Several  of  the  diseased  conditions  which  may  supervene  on  injury, 
such  as  Gangrene,  Erysipelas,  Pyiemia,  Tetanus,  etc.,  will  be  treated  of 
hereafter.  Inflammation  and  its  results.  Suppuration  and  Ulceration, 
have  been  already  described:  and  in  this  place  we  have  to  notice  Shock, 
Traumatic  Fever,  Traumatic  Delirium,  and  the  Remote  Constitutional 
Effects  of  Injury. 

The  effects  resulting  from  injuries  will  be  greatly  modified,  according 
to  the  condition  of  the  patient  at  the  time  of  receipt  of  the  injury,  and 
the  circumstances  in  which  he  is  placed  afterwards.  The  remarks  made 
at  page  18,  in  reference  to  the  conditions  that  influence  the  result  of 
operations,  are  equally  applicable  to  those  forms  of  surgical  injury  that 
are  the  sequence  of  accident,  and  not  inflicted  by  the  Surgeon’s  knife  : 
and  to  these  I  w’ould  refer  the  reader. 

Shock  consists  in  a  disturbance  of  the  functions  of  the  nervous 
system,  whereby  the  harmony  of  action  of  the  great  organs  of  the  body 
becomes  deranged. 

Symptoms. — On  the  receipt  of  a  severe  injury  the  sufferer  becomes 
pale,  cold,  faint,  and  trembling;  the  pulse  is  small  and  fluttering;  there 
is  great  mental  depression  and  disquietude,  the  disturbed  state  of  mind 
revealing  itself  in  the  countenance,  and  in  feebleness  or  incoherence  of 
speech  and  thought ;  the  surface  becomes  covered  with  a  cold  sweat ; 
there  are  nausea,  perhaps  vomiting,  and  relaxation  of  the  sphincters.  In 
severe  shock,  the  temperature,  according  to  Eurneaux  Jordan,  falls  to 
about  97°  Fahr.  in  the  adult.  In  the  young,  the  fall  is  less;  in  the  aged, 
it  is  greater.  Wagstaffe  has  met  with  cases  in  which  recoveiy  has  fol¬ 
lowed  a  fall  of  temperature  amounting  to  four  degrees.  In  fatal  cases 
there  may  be  a  fall  of  as  much  as  six  degrees.  These  symptoms  com¬ 
monly  set  in  immediately  on  the  receipt  of  the  injury.  In  some  cases, 
however,  there  is  an  appreciable  interval  of  time  between  the  infliction 
of  the  injury  and  the  appearance  of  the  shock ;  this  is  more  particularly 


16*0 


CONSTITUTIONAL  EFFECTS  OF  INJURY. 


the  case  in  persons  of  great  mental  fortitude,  or  whose  minds  are  actively 
engaged  at  the  moment  of  the  receipt  of  an  injury.  This  condition 
lasts  for  a  variable  period,  its  duration  depending  on  the  severity  and 
seat  of  the  injury,  on  the  nervous  susceptibility  of  the  patient  and  the 
state  of  his  mind  at  the  time. 

Causes. — Shock  is  partl}^  due  to  mental.,  partly  to  purely  'physical 
causes.  Its  severity  and  continuance  are  thus  materially  influenced 
by  the  moral  condition  of  the  patient,  and  by  the  degree  and  nature  of 
his  injury. 

In  persons  of  a  very  timid  character,  or  of  great  nervous  suscepti¬ 
bility — those  who  are  liable  to  the  occurrence  of  s3uicope — more  espe¬ 
cially  in  females  and  in  children,  a  veiy  trivial  injuiy  may  produce  an 
extreme  degree  of  shock  to  the  nervous  system  ;  indeed,  the  mere  appre¬ 
hension  of  injuiy  ma^",  without  an}"  physical  lesion  being  actually  induced, 
give  rise  to  all  the  phenomena  of  shock  in  its  most  intense  degree. 
People  have  been  actually  frightened  to  death,  without  any  injury  having 
been  inflicted  upon  them.  The  state  of  mind  at  the  time  of  the  receipt 
of  the  injury,  influences  materially  its  effects  on  the  nervous  system. 
If  the  patient  be  anxiously  watching  for  the  infliction  of  a  wound,  as 
w-aiting  for  the  incision  in  a  surgical  operation,  all  the  attention  is  con¬ 
centrated  upon  the  coming  pain ;  it  is  severely  felt,  and  the  consequent 
shock  to  the  system  is  unusually  great.  If,  on  the  other  hand,  the  at¬ 
tention  be  diverted — if,  as  in  the  hour  of  battle,  the  feelings  be  roused 
to  the  highest  pitch,  and  the  mind  in  a  state  of  intense  excitement — a 
severe  injury  may  be  inflicted’,  and  the  patient  may  be  entirely  uncon¬ 
scious  of  it,  feeling  no  pain,  and  experiencing  no  shock,  not  knowing 
perhaps  that  he  is  wounded  till  he  sees  his  own  blood.  The  severity  of 
shock  is  in  a  great  measure  proportioned  to  the  degree  of  pain  attendant 
upon  an  injury.  And,  as  sensibility  to  pain  varies  greatly  in  different 
individuals,  so  will  the  attendant  shock. 

Furneaux  Jordan  has  pointed  out  that  the  functional  activity  of  the 
nervous  system  has  an  important  influence  in  the  production  of  shock. 
In  young  children,  he  observes,  whose  force  is  developmental  rather  than 
nervous  or  muscular,  operations  and  injuries  are  better  borne  than  by 
men  in  the  prime  of  life,  where  all  organs  and  functions  are  subservient 
to  the  exercise  of  nerve-force.  And  the  same  occurs  in  persons  worn  by 
long-standing  local  disease,  which  has  lowered  the  manifestations  of 
vitality  without  impairing  the  integrity  of  the  organs  essential  to  life. 
“  Shock,”  he  says,  “  is  essentially  a  depression  or  metamorphosis  of 
nerve-force.  Where  nerve-force  is  predominant,  shock  also  becomes 
predominant.” 

The  sudden  occurrence  of  a  severe  injury  will,  however,  induce  a  phy¬ 
sical  mpresswn  independently  of  any  mental  emotion  or  moral  influence. 
Thus,  if  a  limb  of  one  of  the  lower  animals,  as  of  a  frog,  be  suddenly 
crushed  by  the  blow  of  the  hammer,  the  force  and  frequency  of  the  heart’s 
action  immediately  become  considerably  lessened.  Here  there  can  be  no 
mental  impression.  So  in  man,  it  is  found  that  the  severity  and  the 
continuance  of  the  shock  are  usually  proportionate  to  the  severity  of  the 
injury,  either  from  its  extent  or  from  the  importance  of  the  part  wounded. 
Thus,  if  the  whole  of  a  limb  be  torn  away  by  a  cannon-shot,  or  crushed 
by  a  railway -train,  the  shock  will  be  severe  from  the  extent  of  the  muti¬ 
lation,  though  the  part  injured  be  not  immediately  necessary  to  life; 
wliilst  on  the  other  hand,  if  a  man  be  shot  by  a  pistol-bullet  though  the 
abdomen,  though  the  extent  of  the  injury  be  trifling,  and  merely  a  few 
drops  of  blood  escape,  yet  the  shock  to  the  system  will  be  severe,  owing 


TREATMENT  OF  SHOCK. 


161 


to  the  importance  in  the  econoni}'  of  the  part  injured.  The  Surgeon  not 
iinfrequently  emplo3^s  this  fact  as  an  accessoiy  means  of  diagnosis. 
Thus,  if  a  man  break  his  leg,  and  at  the  same  time  strike  his  abdomen, 
and  the  shock  be  veiy  serious  and  long  continued,  without  sign  of  rally¬ 
ing,  the  probabilit}' is  that  some  severe  injury  has  been  inflicted  upon  an 
internal  organ  ;  injury  of  the  viscera  occasioning  greater  severity  and 
longer  continuance  of  shock  than  a  wound  of  a  less  vital  part. 

In  extreme  cases,  the  depression  of  power  characterizing  shock  may 
be  so  o-reat  as  to  terminate  in  death.  Jordan  describes  two  kinds  of 

o 

death  from  syncope,  as  being  produced  by  shock.  In  cases  where  the 
impression  is  sudden  and  violent,  the  heart  is  contracted  and  empt}",  or 
nearly  so.  More  frequentl3’,  liowever,  there  is  a  sudden  arrest  of  the 
contractile  power  of  the  heart,  and  its  cavities  contain  more  or  less  par¬ 
tially  coagulated  blood.  In  the  great  majoritj"  of  instances,  however, 
reaction  comes  on,  and  the  disturbed  balance  in  the  s3"stem  is  graduall3'' 
restored.  Not  unfrequentl3^  the  reaction  runs  be3"ond  the  limits  neces¬ 
sary  for  this,  and  a  febrile  state  is  induced,  the  traumatic  fecer^  which 
will  be  presentl3’  described. 

Pathological  Appearances. — There  are  no  absolutel3’’  characteristic 
post  mortem  appearances  after  death  from  shock.  The  heart  is  usuall3" 
found  full  of  blood,  especiall3’  in  the  right  auricle  and  ventricle,  and  the 
whole  venous  S3’stem  is  usuall3"  somewhat  gorged,  unless  the  patient  lias 
lost  much  blood  from  the  accident.  The  blood  was  said  ly  Hunter  to 
remain  fluid  in  some  cases  of  death  from  shock,  but  this  is,  to  say  the 
least,  veiy  rare.  Rigor  mortis  is  usuall3"  well  marked. 

Treatment  of  Shock. — If  the  disturbance  be  chiefly’  mental,  the  patient 
will  usuall3’’  rall3^  speedil3"  on  being  spoken  to  in  a  kind  and  cheering 
manner,  or  on  having  a  little  wine  and  water,  or  ammonia,  administered. 
If  the  shock  be  more  severe,  and  be  the  result  of  considerable  injuiy, 
the  patient  should  be  laid  in  the  recumbent  position,  and  the  injured 
part  arranged  as  comfortabl3'  as  possible ;  he  should  be  wrapped  up  in 
warm  blankets,  hot  bottles  should  be  applied  to  the  feet,  and  friction 
to  the  hands  and  surface;  a  little  warm  tea,  wine,  or  spirits  and  water, 
ma3’  be  administered,  provided  the  insensibility  be  not  complete  ;  if  it 
be  complete,  the  fluid  should  not  be  given,  as  it  might  then  find  its  wa3’’ 
into  the  laiynx.  In  these  circumstances,  ammonia  should  be  applied  to 
the  nostrils,  and  a  stimulating  enema  administered.  When  there  is 
much  pain  associated  with  the  shock,  a  few  drops  of  laudanum  may 
advantageously  be  given.  B3"  such  treatment  as  this,  the  energies  of 
the  nervous  and  vascular  systems  are  gradually  restored ;  and  then  reac¬ 
tion  speedil3"  comes  on. 

A  question  of  considerable  importance  frequently  occurs  to  the  Sur¬ 
geon  in  these  cases ;  viz.,  whether  an  operation  should  be  performed 
during  the  continuance  of  shock.  As  a  general  rule,  it  certainl3"  should 
be  deferred  until  reaction  comes  on,  as  the  additional  injuiy  inflicted  by 
the  operation  would  increase  the  depression  under  which  the  patient  is 
suffering.  In  some  cases,  however,  the  presence  of  a  crushed  limb 
appears  to  prolong  the  shock,  and  thus  prevent  the  patient  from  ral- 
l3dng,  notwithstanding  the  administration  of  stimulants.  In  these  cir¬ 
cumstances  the  Surgeon  w'ould  be  justified  in  operating  before  reaction 
came  on.  Here  the  administration  of  chloroform  in  moderate  quantity 
is  extremel3"  beneficial :  it  exercises  a  sustaining  influence,  not  01113''  by 
acting  as  a  stimulant  to  the  nervous  S3’stem,  but  b3'  preventing  the  pain 
and  dread  of  the  operation  from  still  further  depressing  the  vital  ener¬ 
gies.  In  these  cases  of  long-continued  shock,  great  care  is  required  in 
VOL.  I. — II 


162 


CONSTITUTIONAL  EFFECTS  OF  INJURY. 


ascertaining  that  there  is  no  internal  injury  giving  rise  to  the  depres¬ 
sion,  but  that  the  shock  is  really  dependent  upon  the  mangled  limb. 

After  the  immediate  effects  of  the  shock  have  entirely  passed  away, 
we  must  adopt  means  to  prevent  the  remote  consequences.  With  this 
view — if  the  patient  can  bear  it — bloodletting  is  often  of  essential  ser¬ 
vice,  and  is,  I  think,  far  too  much  neglected  at  the  present  day.  In 
addition  to  this,  the  patient’s  diet  and  habits  of  life  should  be  carefully 
regulated,  over-stimulation  being  especially  avoided  ;  his  bowels  should 
be  kept  freely  open,  and  his  general  health  attended  to. 

Traumatic  Fever. — After  the  immediate  effects  of  shock  have 
passed  off,  the  reaction  which  ensues  may  not  pass  the  limits  of  health. 
In  other  cases,  however,  and  also  in  instances  where  the  shock  may 
have  been  but  slight,  a  general  febrile  state  arises.  This  febrile  condi¬ 
tion,  following  injuries  and  surgical  operations,  has  been  ably  iiiA’esti- 
gated  and  described  in  late  years,  especially  by  Billroth,  of  Vienna, 
who  distinguishes  between  the  true  traumatic  fever^  occurring  at  an 
earl}’’  period  after  the  receipt  of  the  injury,  and  inflammatory  secondary 
fecer^  the  result  of  the  supervention  of  inflammation  in  the  vicinity  of 
the  wound. 

Traumatic  Fever  is,  according  to  Billroth,  the  result  of  the  absorp¬ 
tion  of  decomposed  materials  from  the  surface  of  the  wound.  It 
generally  commences  on  the  second  day,  and,  after  increasing  rapidl}^, 
remains  (with  remissions)  at  nearly  the  same  height  for  nine  days,  and 
then  ceases.  The  temperature  may  rise  to  102°  or  even  104°  Fahr. 
The  pulse  is  generally  frequent  in  proportion  to  the  temperature.  The 
decline  or  defervescence  of  the  fever  is  sometimes  rapid,  occurring  in  a 
period  varying  from  twenty-four  to  thirty-six  hours ;  sometimes  it  is 
slow,  and  in  these  cases  Billroth  has  noticed  it  to  be  attended  by  evening 
exacerbations. 

Inflammatory  Fever  usually  arises  from  inflammation  of  the  parts  in 
the  neighborhood  of  the  wound,  and  may  be  the  result  of  the  slow 
throwing  off  of  destro3’’ed  tissues,  as  fascia  or  tendon,  or  of  the  pre¬ 
sence  of  foreign  bodies.  It  may  also  be  produced  by  retained  secretions 
in  closed  wounds,  or  by  retention  of  the  faeces  and  urine,  or  by  consecu¬ 
tive  inflammation  of  other  organs  and  tissues.  It  may  occur  when  there 
have  been  no  appreciable  symptoms  of  traumatic  fever  ;  or  it  may 
follow’  the  traumatic  fever.  Its  course,  variations,  and  treatment  have 
been  alread}^  described  in  speaking  of  the  febrile  conditions  consecutive 
on  inflammation  (see  Chapter  lY.). 

Traumatic  Delirium  not  unfrequently  occurs  in  cases  of  severe 
injury  in  individuals  with  an  irritable  nervous  system,  particularly  in 
those  who  have  been  drinking  freely  before  or  were  intoxicated  at  the 
time  of  the  accident.  It  usually  comes  on  about  the  third  or  fourth 
day,  but  not  unfrequentl}’’  earlier  than  this ;  and  most  commonly 
declares  itself  during  the  night.  This  disease  presents  two  distinct 
types,  which  are,  in  fact,  different  diseases — the  one  inflammatory^  the 
other  irritative. 

In  Inflammatory  Traumatic  Delirium  there  are  a  quick  and  bounding 
pulse,  hot  skin  and  head,  flushed  cheeks,  glistening  eyes,  much  thirst, 
and  high  febrile  action  generally.  The  delirium  is  usually  furious ;  the 
patient  shouting,  singing,  tossing  himself  about  the  bed,  and  moving 
the  injured  limb,  insensible  to,  or  regardless  of,  pain. 

The  Treatment  of  this  form  of  the  disease  should  be  depletor3\ 
Bleeding  from  the  arm,  with  leeches  and  ice  to  the  head,  purging  and 
low  diet,  will  subdue  it ;  but  in  many  cases  it  is  speedily  fatal. 


TRAUMATIC  DELIRIUM. 


163 


The  Irritative  or  Nervous  Delirium  usually  occurs  in  persons  of  a 
broken  constitution,  and  closel}^  resembles  ordinary  delirium  tremens  ; 
sometimes  it  is  preceded  by  a  fit  of  an  epileptic  character.  In  this  form 
of  the  disease  the  pulse  is  quick,  small,  and  irritable;  the  pupils  dilated; 
the  surface  cool ;  the  countenance  pale,  with  an  anxious,  haggard 
expression,  and  bedewed  with  a  clammy  sweat.  The  tongue  is  white, 
and  there  is  sometimes  tremor  of  it  and  of  the  hands  ;  but  this  by  no 
means  invariably  occurs.  The  delirium  is  usuall}^  of  a  muttering  and 
suspecting  character ;  the  patient  is  often  harassed  by  spectral  illu¬ 
sions,  but  will  answer  rationally  when  spoken  to.  This  form  of  disease 
is  sometimes  very  rapidl}^  fatal.  I  have  known  it  to  destroy  life  in  cases 
of  simple  fracture  in  less  than  twelve  hours. 

The  Treatment  of  irritative  traumatic  delirium  consists  essentially  in 
the  administration  of  opium  until  sleep  is  procured,  or  the  pupil  becomes 
protracted.  For  this  purpose  large  quantities  are  frequently  required ; 
and  the  drug  should  be  given  in  full  doses,  and  repeated  every  second  or 
third  hour.  If  there  be  much  depression,  it  will  usually  be  expedient  to 
administer  the  opiate  in  porter,  or  in  that  stimulant  to  which  the  pa¬ 
tient — if  a  drunkard — has  habituated  himself  The  administration  of 
the  opiate  should  be  preceded  by  a  free  purge  and  an  aperient  enema,  so 
that  all  source  of  irritation  may  be  removed  from  the  intestinal  canal. 
A  strait  waistcoat  is  commonly  necessary  in  all  cases  of  traumatic  de¬ 
lirium,  in  order  to  prevent  the  patient  from  injuring  the  wounded  part. 
After  sleep  has  been  induced,  the  quantity  of  the  opiate  must  be  lessened ; 
but  it  will  be  found  necessaiy  to  continue  it  for  some  time,  as  there  will 
be  a  tendency  to  the  recurrence  of  the  delirium  at  night. 

These  two  forms  of  traumatic  delirium,  the  inflammatory  and  the 
irritative,  are  often  found  more  or  less  conjoined;  a  modification  of  the 
treatment  then  becomes  requisite, — the  Surgeon  depleting  with  one 
hand,  and  allaying  irritation  by  opiates  and  giving  support  with  the 
other. 

The  effects  resulting  from  injuries  will  be  greatly  modified,  according 
to  the  condition  of  the  patient  at  the  time  of  the  receipt  of  the  injury, 
and  the  circumstances  in  which  he  is  placed  afterwards.  The  remarks 
made  at  page  18,  in  reference  to  the  conditions  that  influence  the  result 
of  operations,  are  equally  applicable  to  those  forms  of  surgical  injury 
that  are  the  result  of  accident,  and  not  inflicted  by  the  Surgeon’s  knife; 
and  to  them  I  would  refer  the  reader. 

Remote  Effects  of  Injury. — These  may  be  constitutional  or  local. 

The  Remote  Constitutional  Effects  of  injuries  are  of  a  very  varied 
character.  In  some  cases,  persons  who  have  met  with  serious  injury 
will  be  found  to  die  suddenly,  some  months  after  apparent  recovery. 
In  others,  they  gradually  fall  out  of  health,  the  nutrition  of  the  body 
appearing  to  become  impaired,  and  anaemia  and  a  cachectic  state  super¬ 
vening.  In  other  instances,  again,  the  functions  of  the  nervous  system 
become  disturbed:  convulsive  movements  or  paralytic  symptoms  of  a 
slight  but  persistent  character  eventually  develop  themselves,  and  may 
become  progressive,  terminating  in  organic  disease  of  the  nervous  cen¬ 
tres.  In  these  cases,  the  immediate  influence  exercised  by  the  injury  on 
the  nervous  system  seems  to  pass  off,  while  a  permanent  impression  is 
left.  The  patient  never  completely  recovers  from  the  effects  of  his 
injury:  he  is  never,  to  use  the  common  expression,  “the  same  man 
again ;”  and,  although  his  health  may  appear  to  improve  from  time  to 
time,  yet,  on  close  inquiiy  and  careful  investigation,  it  will  be  found 


164 


INJURIES  OF  SOFT  PARTS. 


that  there  has  been  a  continuous  train  of  symptoms  indicative  of  a 
disordered  state  of  the  nervous  s3'stem. 

These  remoteconstitutional  effects,  to  which  attention  has  been  directed 
b}’’  Hodgkin  and  James,  often  do  not  manifest  themselves  for  weeks  or 
months  after  the  infliction  of  the  injury.  Some  change  appears  to  be 
induced  in  the  condition  of  the  blood,  or  in  the  action  of  the  nervous 
s3'Stem,  that  is  incompatible  with  health.  Perhaps,  as  Hodgkin  sup¬ 
poses,  the  part  locally  injured  becomes  incapable  of  proper  nutritive 
action,  and  thus  a  morbid  poison  results,  in  consequence  of  some  pecu¬ 
liar  combination  of  the  chemical  elements  of  the  part,  b3^  which  the 
whole  S3’stem  is  influenced.  Be  this  as  it  ma3’',  the  fact  remains  certain, 
that  constitutional  disturbance,  serious  illness,  or  even  sudden  death, 
ma3'  supervene,  as  a  consequence  of  a  local  injuiy,  a  considerable  time 
after  its  infliction. 

Remote  Local  Consequences. — There  can  be  little  doubt  that  many 
structural  diseases  owe  their  origin  to  this  cause.  The  nutrition  of  a 
part  ma3-  be  modified  to  such  an  extent  b3"  a  blow  or  wound  inflicted 
upon  it,  as  to  occasion  those  alterations  in  the  structure  which  consti¬ 
tute  true  organic  disease.  Thus  we  occasionall3^  find,  on  death  resulting,' 
some  months  after  a  severe  injuiy,  that  extensive  local  mischief,  usually 
of  an  inflammatory  character,  is  disclosed,  which  has  evidently  been 
going  on  in  an  insidious  manner  from  the  time  of  the  accident. 

In  other  cases  again,  a  blow  ma3^  give  rise  to  severe  and  long-con¬ 
tinued  neuralgic  pains  in  a  part,  or  it  may  be  the  direct  occasioning 
cause  of  structural  disease  in  bones,  joints,  or  bloodvessels;  and,  lastly, 
the  origin  of  many  cases  of  cancer  can  be  distinctly  referred  to  external 
violence. 


CHAPTEE  IX. 

INJURIES  OF  SOFT  PARTS. 

These  consist  of  Contusions  and  Wounds. 

CONTUSIONS. 

In  a  Contusion  the  skin  is  unbroken,  but  there  is  alwa3"S  some  lacera¬ 
tion  of  the  subcutaneous  structures.  Indeed,  great  disorganization  of 
these  occasionall3’  takes  place,  though  the  skin  continues  entire,  owing 
to  its  greater  elasticit3’^  and  toughness.  Hence  a  contusion  may  be 
looked  upon  as  being  a  subcutaneous  lacerated  wound. 

In  contusions  there  is  always  extravasation  of  blood  into  the  tissues  to 
a  greater  or  less  degree.  When  slight,  this  extravasation  is  termed  an 
ecchymosis.  The  blood  is  not  shed  outwardH,  but  accumulates  under 
the  skin  in  the  areolar  tissue,  or  in  internal  organs,  presenting  in  the 
former  situation  the  ordinaiy  purplish-black  discoloration  of  a  bruise. 
The  amount  of  blood  extravasated  will  of  course  ilepend  upon  the  vascu- 
larit3’  of  the  part  contused.  The  arrest  of  the  extravasation  takes  place 
in  a  great  measure  by  the  effused  blood  pent  up  amongst  the  tissues 
coagulating  over  and  compressing  the  torn  vessels  which  have  poured  it 
forth,  and  thus  restraining  the  further  escape  of  blood  from  them,  and 
allowing  the  ordinaiy  process  of  repair  of  wounded  vessels  to  take  place. 


DEGREES  OF  CONTUSION. 


165 


Causes. — Contusions  may  result  ivom  direct  pressure^  as  when  a  part 
is  forcibly’  squeezed;  from  a  direct  bloiv^  usually  by  a  hard  blunt  body; 
or  from  an  indirect  bloiv^  as  when  the  hip-joint  is  contused  by  a  person 
falling  on  his  feet  from  a  height. 

Compression  of  the  parts  injured  is  always  necessary  to  constitute  a 
contusion.  This  compression  may  occur  between  the  force  on  one  side, 
and  a  bone  as  the  resisting  medium  on  the  otlier;  or  the  part  injured 
may  be  compressed  and  contused  between  two  forces  in  action — as  when 
the  hand  is  caught  between  two  revolving  wheels ;  or  between  a  force  in 
action  and  a  passive  medium — as  b}^  a  wheel  passing  over  the  limb  and 
crushing  it  against  the  ground. 

Degrees, — The  amount  of  extravasation  of  blood  consequent  on  a 
contusion  will  necessarily  mainly  depend  upon  the  force  employed  in 
its  production,  but  also  to  some  considerable  extent  upon  the  state  of 
health  of  the  individual  bruised.  In  persons  out  of  health,  with  soft 
tissues  and  the  blood  in  a  low  crasis,  bruising  very  readily  occurs.  Con¬ 
tusions  are  of  various  degrees:  the}"  may  be  arranged  as  follows:  1,  of 
the  Skin  simply ;  2,  with  Extravasation  into  the  Areolar  Tissue ;  3,  with 
Subcutaneous  Laceration  of  the  Soft  Parts;  and  4,  with  Subcutaneous 
Disorganization  of  the  Soft  and  Hard  Parts. 

In  the  first  degree^  the  blood  is  merely  effused  into  the  skin,  producing 
ecchymosis  or  bruise;  the  color  of  which  varies  from  purplish-red  to 
greenish-brown,  this  variation  being  dependent  upon  changes  that  take 
place  in  the  extravasated  blood  as  it  undergoes  absorption. 

In  the  second  degree  a  bag  of  blood  can  often  be  felt  fluid  and  fluctu¬ 
ating  under  the  skin,  in  which  state  it  may  remain  for  weeks  or  even 
months  without  undergoing  any  material  change,  provided  it  be  ex¬ 
cluded  from  the  air.  In  other  cases  it  gradually  becomes  absorbed  ;  or, 
if  it  communicate  with  the  air,  the  bag  being  opened  in  any  way,  it  may 
undergo  disintegration,  suppuration  taking  place  around  it,  and  the 
clots  discharging  through  an  abscess.  In  some  cases  it  would  appear, 
from  the  observations  of  P.  Hewett  and  of  Paget,  that  the  clot  result¬ 
ing  from  extravasated  blood  may  become  organized  and  finally  pene¬ 
trated  by  bloodvessels.  The  French  pathologists  have  described  the 
formation  of  a  cyst  containing  serous  fluid  in  the  site  of  the  extravasated 
blood.  These  cysts  are  composed  of  a  fibrous  structure,  but  without 
cells  ;  they  have  no  distinct  lining  membrane,  and  in  their  interior  se¬ 
rous  or  grumous  fluid,  composed  of  disintegrated  blood,  is  found.  In 
other  cases  the  serous  or  fluid  parts  are  absorbed,  and  the  fibrinous 
matters,  forming  cheesy  concretions,  are  left  behind.  Lastly,  extrava¬ 
sated  blood  may  give  rise  to  a  sanguineous  tumor,  Heematoma^  the  blood — 
continuing  for  months,  or  even  years,  fluid,  but  still  not  unchanged — 
becoming  darker,  treacly,  and  more  or  less  disintegrated,  and  eventually 
intermixed  with  various  products  of  inflammation. 

In  the  third  and  fourth  degrees  of  contusion  the  laceration  and  disor¬ 
ganization  of  structures  usually  lead  to  sloughing  and  suppuration,  or  to 
rapid  gangrene  of  the  parts,  or  to  hemorrhage,  ending  in  fatal  syncope; 
or,  when  the  contusion  is  of  an  internal  organ,  this  hemorrhage  may 
prove  fatal  by  taking  place  into  the  serous  cavities.  When  the  contu¬ 
sion  is  superficial,  the  hemorrhage  is  subcutaneous,  and,  though  abun¬ 
dant,  is  rarely  in  sufficient  quantity  to  influence  the  heart’s  action.  In 
one  remarkable  case,  how^ever,  in  which  a  schoolmaster  was  convicted 
of  manslaughter  for  beating  a  boy  to  death  with  a  stick,  and  in  which  I 
was  called  to  make  a  post-mortem  examination,  death  had  evidently  re¬ 
sulted,  in  a  great  measure  at  least,  from  this  cause ;  the  subcutaneous 


166 


IlSrJUEIES  OF  SOFT  PAETS. 


areolar  tissue  of  the  four  limbs  being  extensively^  torn  away  from  the 
fasciae,  and  uniformly  filled  with  extravasated  blood,  whilst  the  internal 
organs  were  in  an  anaemic  condition,  the  pulmonary  vessels  and  the 
coronary  arteries  of  the  heart  even  being  emptied  of  blood. 

Diagnosis. — This  is  not  always  easy.  The  minor  degrees  may  be 
mistaken  for  incipient  gangrene,  the  discoloration  not  being  very  dis¬ 
similar ;  but  the  part,  when  simply  contused,  preserves  its  temperature 
and  vitality.  In  some  places  the  extravasated  blood  has  a  hard  cir¬ 
cumscribed  border,  and  is  soft  in  the  centre,  thus  resembling  somewhat 
a  depression  in  the  subjacent  bone.  This  is  especially^  the  case  in  some 
bruises  about  the  scalp. 

The  diagnosis  of  old  cases  of  extravasation,  leading  to  hmmatoma, 
from  abscess  or  malignant  disease,  is  not  alway's  easily  made  by^  tactile 
examination  only ;  but  the  history  of  the  case,  exploration  with  a  grooved 
needle,  and  examination  of  the  contents  of  the  tumor  under  the  micros¬ 
cope,  will  always  clear  up  any^  doubt  that  may^  exist. 

Treatment. — In  the  first  two  degrees  of  contusion  our  great  object 
should  be  to  excite,  as  speedily^  as  possible,  the  absorption  of  the  ex¬ 
travasated  blood.  Here  cold  applications  are  of  especial  service  ;  lotions 
composed  of  one  part  of  spirits  of  wine  to  eight  or  ten  of  water  should 
be  constantly’  applied.  Leeches — commonly  used  in  these  cases — should 
not  be  applied  to  a  bruised  part ;  they  cannot  remove  the  blood  that  has 
already^  been  extravasated,  and  often  set  up  great  irritation,  which  leads 
to  suppuration.  The  bag  of  blood  should  never  be  opened,  however  soft 
and  fluctuating  it  may’’  feel,  so  long  as  there  is  any^  chance  of  procuring 
its  absorption  by  discutient  remedies.  If  once  it  be  punctured  and  air 
be  allowed  to  enter,  putrefactive  suppuration  will  be  set  up  in  it.  But 
if  signs  of  inflammation  occur  around  it,  the  parts  becoming  red,  hot, 
and  painfully  throbbing,  free  incisions  should  at  once  be  made,  the 
blood — already  disorganized  and  mixed  with  pus — be  discharged,  and 
the  cavity  allowed  to  granulate.  Purging  and  general  depletory  treat¬ 
ment  will  often  promote  absorption  of  the  extravasation. 

In  the  third  and  fourth  degrees  of  contusion,  it  is  generally  useless  to 
attempt  to  save  the  life  of  the  injured  part.  Here  poultices  must  be 
applied  to  hasten  suppuration  and  the  separation  of  the  sloughs;  the 
ulcer  that  results  being  treated  on  general  principles. 

Disorganizing  contusions  of  the  most  severe  kind  may  be  recovered 
from ^  provided  there  he  no  external  wound^  even  though  the  soft  struc¬ 
tures  of  the  limb  or  part  be  extensively’  crushed,  the  bones  comminuted, 
and  the  joints  opened.  It  is  not  the  subcutaneous  lacerations  and  dis¬ 
organizations  that  are  to  be  dreaded  ;  so  long  as  the  main  bloodvessels 
of  the  part  injured  are  intact,  these  may  be  recovered  from.  But  it  is 
the  admission  of  air  into  the  interior  of  a  badly-injured  limb  that  con¬ 
stitutes  the  great  danger.  If  this  can  be  avoided  there  is  little  fear  of 
undue  inflammation  being  excited,  provided  proper  precautions  are 
taken  ;  but  if  air  be  once  admitted  into  the  lacerated  tissues,  suppurative 
and  sloughing  action  is  at  once  set  up,  and  the  safety’’  of  the  patient  will 
be  seriously  imperilled.  In  such  cases  as  these,  amputation  is  usually 
the  sole  resource,  unless  the  progress  of  the  mischief  can  be  arrested 
by^  the  employ’ment  of  the  antiseptic  treatment  (p.  172)  or  some  equally 
efficient  plan. 

The  difference  between  the  effects  of  a  subcutaneous  laceration  and 
one  accompanied  by  open  wound  is  well  exemplified  in  the  cases  of  a 

simple”  and  a  “  compound”  dislocation.  In  the  first  case,  although 
the  ligaments  and  capsular  muscles  are  extensively’  torn,  often  with 


SYMPTOMS  OF  INCISED  WOUNDS. 


167 


great  extravasation  of  blood,  repair  takes  place  without  an}''  serious 
trouble,  often  with  scarce  any  inflammatory  action ;  whilst  in  the  com¬ 
pound  dislocation,  where  air  has  been  admitted,  the  most  extensive  sup¬ 
purative  action  necessarily  ensues,  and  joint,  limb,  or  life,  one  or  other, 
is  in  great  danger  of  being  irretrievably  lost. 

Contusions  of  internal  organs  are  always  of  a  very  serious  character, 
and  require  special  treatment,  according  to  the  part  that  is  affected,  and 
the  extent  of  its  injury. 

Strangulation  of  Farts. — This,  when  accidental,  occasionally  oc¬ 
curs  as  the  consequence  of  the  application  of  a  constricting  ligature  or 
bandage,  or  by  the  accidental  slipping  of  a  tight  ring  over  a  part.  In 
such  cases  the  first  effect  of  the  constriction  is  to  prevent  the  return  of 
the  venous  blood  from  the  part  beyond  that  to  which  it  is  applied  ;  this 
impediment  to  the  circulation  occasions  serous  effusion,  and  hence 
swelling  of  an  oedematous  character.  If  relief  be  not  afforded  to  the 
circulation  by  the  removal  of  the  constricting  cause,  distention  of  the 
vessels,  stagnation  of  the  blood,  loss  of  vitality  of  the  part,  and  gan¬ 
grene  will  speedily  ensue.  Hence  the  treatment  consists  in  at  once 
dividing  or  removing  the  cord  or  ring,  as  the  case  may  be.  Usually 
this  is  easily  done,  but  in  some  cases  it  is  attended  with  no  little  diffi¬ 
culty.  This  especially  happens  when  a  small  ring  has  been  hurriedly 
put  on  a  wrong  finger,  or  when  the  penis  has  been  drawn  through  a  brass 
ring.  In  such  cases  as  these  the  member  swells  greatly,  and  the  diffi¬ 
culty  of  removing  the  foreign  body  is  very  considerable.  The  finger¬ 
ring  may  usually  be  removed  by  slipping  a  director  under  it,  and  clip¬ 
ping  or  filing  it  across  upon  this.  Sometimes  the  following  popular  plan 
may  advantageously  be  adopted  :  A  strong  silk  thread  is  carefully  wound 
round  the  finger  as  tightly  as  possible  from  the  point  down  to  the  ring, 
and  through  this  the  free  end  is  carried  with  a  needle  :  the  thread  is  then 
slowly  untwisted,  and  the  ring  is  thus  carried  upon  it  off  the  finger. 
Curtain  or  other  brass  rings  compressing  the  root  of  the  penis  have 
been  known  slowly  and  gradually  to  cut  through  the  organ,  without 
destroying  its  vitality  or  rendering  the  urethra  impervious.  But  such  a 
fortunate  result  is  altogether  the  exception  ;  in  the  great  majority  of 
such  cases,  unless  the  ring  be  speedily  cut  off,  mortification  of  the  organ 
would  ensue,  and  might  be  followed,  as  it  has  been  in  some  instances,  by 
the  death  of  the  patient. 


WOUNDS. 

A  wound  may  be  defined,  in  the  words  of  Wiseman,  as  “  a  solution  of 
continuity  in  any  part  of  the  body,  suddenly  made  by  anything  that 
cuts  or  tears,  with  a  division  of  the  skin.” 

Surgeons  divide  wounds  into  Incised^  Lacerated^  Contused^  Punctured^ 
and  Poisoned. 

Incised  Wounds  may  vary  in  extent  from  a  simple  superficial  cut 
to  the  incision  required  in  amputation  at  the  hip-joint.  Incised  wounds 
are  usually  open,  the  air  having  free  access  to  them ;  occasionally, 
however,  when  made  by  the  Surgeon,  they  are  subcutaneous,  only  com¬ 
municating  externally  by  a  small  puncture.  They  may  be  simple, 
merely  implicating  integument  and  muscle;  or  they  may  be  compli¬ 
cated  with  injury  of  the  larger  vessels  and  nerves,  or  of  important 
organs. 

Symptoms  — In  all  cases  incised  wounds  give  rise  to  three  symptoms ; 
viz..  Pain,  Hemorrhage,  and  Separation  of  their  Sides. 


168 


INJURIES  OF  SOFT  PARTS. 


The  Pain  in  an  incised  wound  is  usually  of  a  cutting,  burning,  or 
smarting  character.  Dr.  J.  Johnson  compared  his  own  sensations  to 
the  pain  produced  by  a  stream  of  molten  lead  falling  upon  the  part. 
Much  depends,  however,  on  the  extent  and  situation  of  the  wound  ; 
and  also  whether  the  cut  has  been  made  from  the  cutaneous  surface 
inwards,  or  from  within  outwards;  in  the  former  case  the  pain  is  greater 
than  in  the  latter,  owing  to  the  nerves  being  divided  from  the  branches 
towards  the  trunk;  whereas,  when  the  direction  of  the  cut  is  round, 
the  trunks  are  divided  first,  and  the  branches,  being  paralj^zed,  do  not 
feel  the  subsequent  incision. 

The  amount  of  Hemorrhage  necessarily  depends  upon  the  vascularity 
of  the  part  as  well  as  on  the  size  of  the  wound.  The  proximitj^  of  the 
part  wounded  to  the  centre  of  the  circulation,  or  to  a  large  vessel,  also 
influences  this  veiy  considerably,  different  parts  of  the  same  tissue 
bleeding  with  different  degrees  of  facility ;  thus  the  skin  of  the  face 
yields  more  blood  when  cut  than  that  of  the  leg.  Again,  the  same  parts 
will,  under  different  states  of  irritation,  pour  out  different  quantities; 
e.  g.^  the  cut  surface  of  the  tonsils  has  been  known  to  bleed  after  their 
partial  excision  to  such  an  extent  as  to  cause  death,  although  usually 
but  a  few  drops  are  lost. 

The  Separation  of  the  lips  of  the  wound  depends  on  the  tension  and 
the  position  of  the  part  as  well  as  on  the  elasticit}^  and  vital  contractility 
of  the  tissues ;  it  is  also  influenced  b}’’  the  direction  of  the  incision, 
according  as  this  is  parallel  to  or  across  the  axis  of  a  limb  or  muscle. 
It  is  greatest  in  those  parts  that  are  naturally  the  most  elastic  or  that 
possess  the  highest  degree  of  tonicity  ;  thus  the  muscles  when  cut 
retract  some  inches,  the  arteries  and  skin  gape  widely  when  divided, 
whereas  in  the  ligaments  or  bones,  no  retraction  takes  place. 

Management  of  Incised  Wounds. —  In  the  treatment  of  an  incised 
wound,  we  must  alwa3's  endeavor  to  procure  union  directl}’-  or  by  adhe¬ 
sive  inflammation  between  a  portion,  if  not  the  whole,  of  the  surfaces, 
for  reasons  already  assigned.  The  probability  of  procuring  adhesive 
union  depends  greatlj'  upon  the  constitution  of  the  patient ;  it  is  a 
decided  and  most  dangerous  error,  and  as  unscientific  as  it  is  dangerous, 
to  suppose  that  it  is  entirel}’’  dependent  on  local  conditions  and  the  man¬ 
agement  of  the  wound  itself.  In  some  constitutions  it  is  impossible, 
under  the  most  favorable  circumstances,  to  obtain  it.  The  sounder  the 
constitution,  the  more  readily  will  union  b^'  the  first  intention  take 
place,  and  in  all  cases  it  is  disposed  to  by  the  removal  of  all  sources  of 
irritation  from  the  system,  and  by  the  adoption  of  a  supporting  regi¬ 
men.  Repair,  like  all  other  phj^siological  processes,  is  attended  with  an 
expenditure  of  vital  force  directly  proportioned  to  the  extent  to  which 
plastic  material  is  separated  from  the  blood  ;  hence  an^dhing  approaching 
to  a  lowering  plan  of  treatment  is  to  be  avoided,  though  the  opposite 
error  of  over-stimulation  is  equallj'  to  be  deprecated.  Thus,  in  those 
operations,  the  plastic,  for  instance,  in  which  it  is  necessar}^  that  the 
union  be  as  direct  as  possible,  the  patient  should  be  prepared  bj’'  being 
kept  for  some  time  previousl^^  upon  a  diet  chiefly  consisting  of  milk 
and  light  animal  food,  by  taking  regular  exercise,  and  by  the  adminis¬ 
tration  of  iron ;  we  should  also  look  speciall}^  to  the  state  of  the  diges¬ 
tive  and  urinary  organs.  In  cases  of  accidental  W'ound,  we  must  keep 
the  patient  quiet,  put  him  on  a  moderate  diet,  and  be  very  cautious  in 
the  administration  of  stimulants,  as  they  have  a  great  tendency  to 
interfere  with  union  by  the  first  intention.  It  must  be  borne  in  mind, 
that  the  great  object  is  to  limit  inflammation ;  for  if  this  be  carried 


LOCAL  TREATMENT  OF  INCISED  WOUNDS. 


169 


beyond  what  is  necessary  for  plastic  efi'nsion,  suppurative  action  will 
certainly  follow.  We  must  not  lose  sight,  too,  of  the  fact,  that  homo- 
geneit}"  of  tissue  in  the  opposed  surfaces  is  essential  to  union  by  the 
first  intention.  When  these  are  soft  and  uniform  in  structure,  as  in 
the  face  or  perineum,  union  will  readily  take  place  when  the  divided 
edges  are  placed  in  contact ;  but  if  they  be  dissimilar,  we  cannot  expect 
it:  e.  g.,  muscle  will  not  adhere  to  cartilage,  nor  tendon  to  bone. 

Local  Treatment  of  Incised  Wounds. — There  are  three  chief  indica¬ 
tions  in  the  management  of  an  incised  wound  ;  1,  the  Arrest  of  Hemor¬ 
rhage ;  2,  Removal  of  Foreign  Bodies ;  and  3,  Coaptation  of  the  Sides 
of  the  Wound. 

1.  If  bleeding  be  general  from  the  surface,  it  may  be  stopped  by 
exposure  to  the  air,  by  elevation  of  the  wounded  part,  by  accurate  and 
firm  coaptation,  bj-  the  pressure  of  a  well-applied  bandage,  or  of  the 
finger  over  the  spot,  and  by  the  use  of  cold  or  other  styptics ;  if  it  be 
arterial,  by  ligature,  tension,  or  acupressure.  In  making  choice  of  a 
hemostatic,  preference  is  to  be  given  to  those  that  will  interfere  the 
least  with  union  by  the  first  intention.  Thus,  amongst  stj’ptics,  cold,  in 
the  shape  of  ice,  or  rags  wrung  out  of  cold  water,  is  to  be  preferred  to 
others  of  the  same  class,  such  as  the  perchloride  of  iron,  which  are  all 
more  or  less  caustic  and  irritant.  Again,  torsion  should  be  employed 
when  it  can  be  done  with  safet3',  rather  than  the  ligature,  which,  b}^  its 
retention  in  the  wound,  offers  an  obstacle  to  the  occurrence  of  primary 
union.  In  short,  the  simpler  the  remedy"  the  better. 

2.  The  Removal  of  Foreign  Bodies.,  such  as  dirt,  pieces  of  stone  and 
glass,  spicula  of  bone,  coagulated  blood,  etc.,  is  best  effected  bj^  allowing 
a  stream  of  water  from  a  sponge  or  irrigator  to  fall  upon  the  part,  all 
rough  handling  of  the  wounded  tissue  being  avoided  as  much  as  pos¬ 
sible.  Sharp  and  angular  bits  imbedded  amongst  the  tissues  should  be 
removed  bj^  forceps.  Above  all,  this  cleansing  of  the  wound  is  to  be 
done  thorough^,  and  once  for  all ;  a  comparatively^  insignificant  body, 
if  overlooked  at  this  time,  may  effectually’  prevent  adhesion  by  setting 
up  suppurative  action,  whilst  disturbance  of  the  wound  after  it  lias  been 
once  closed,  destroys  the  layer  of  effused  fibrine  which  ought  to  form 
the  bond  of  union. 

3.  The  last  and  most  important  indication  to  fulfil,  is  the  Coaptation 
of  the  Ojwosed  Surfaces  and  the  Exclusion  of  Air  as  accurately’  as 
possible. 

As  a  general  rule,  the  sides  should  not  be  brought  together  until  all 
hemorrhage  has  ceased;  if,  however, there  be  but  slight  oozing, this  may 
be  arrested  by  their  approximation.  If  the  wound  be  extensive  it  is 
advantageous  to  wait  for  a  few  hours,  until  its  sides  are  glazed  over  by 
a  lay’er  of  fibrin.  Before  doing  so,  however,  the  whole  extent  of  the 
wound  should  be  washed  with  an  antiseptic  solution,  to  obviate  as  much 
as  possible  subsequent  decomposition.  For  this  purpose  a  watery’  solu¬ 
tion  of  carbolic  acid  (1  to  50)  is  the  best;  some  prefer  a  lotion  (10  gr. 
to  ^i)  of  chloride  of  zinc,  sulphuric  acid,  or  ether.  The  surfaces  should 
then  be  gently  brought  together,  from  behind  forwards,  so  as  to 
thoroughly  exclude  all  air  and  superfluous  moisture  from  the  deeper 
portions  of  the  w’ound,  the  skin  margin  being  the  last  to  be  adjusted  ; 
due  attention  should  at  the  same  time  be  paid  to  relaxing  the  parts  by 
position,  so  that  there  may  be  no  gaping  of  the  lips  nor  tension  on  the 
sides  of  the  wound. 

The  arrangement  of  the  parts  should  be  such  that  there  may  be  a 
ready  escape  for  the  serous  oozing,  which  must  necessarily’  ensue  in 


170 


INJURIES  OF  SOFT  PARTS. 


wounds  that  do  not  at  once  adhere  throughout  their  whole  extent.  This 
should  be  allowed  to  take  place  from  what  will  be  eventually  the  most 
dependent  point  of  the  cut ;  and  where  ligatures  have  been  used,  the 
threads  should  be  brought  out  at  the  same  spot.  For  the  purpose  of 
keeping  all  in  position,  sutures^  plasters,  and  bandages  are  employed. 

Sutures  are  employed  when  there  is  more  tendency  to  gaping  than  can 
be  overcome  by  position  or  plasters.  Metallic  threads  of  well-annealed 
silver  or  iron  wire,  of  various  degrees  of  stoutness,  are  now  more  gene¬ 
rally  used  than  those  of  silk,  as  they  are  less  irritating,  are  incapable  of 
imbibing  the  secretions  of  the  wound,  and,  when  once  adjusted,  keep  the 
form  first  given  to  them.  In  cases,  however,  where  the  sutures  are  only 
retained  for  a  day  or  two,  it  is  not  of  much  moment  which  material  is 
used ;  if  it  be  silk,  it  should  be  that  known  as  dentists’  or  twisted  silk, 
well  waxed,  the  thickness  varying  with  the  nature  and  situation  of  the 
injury.  Thus,  in  wounds  of  the  limbs,  where  much  traction  may  be 
expected,  the  suture  should  be  thick ;  whilst  in  those  cases  in  which  it 
is  of  importance  that  as  little  deformity  as  possible  should  be  left,  e.  g.,  in 
plastic  operations  and  in  wounds  about  the  face,  it  should  consist  of  the 
finest  material  compatible  with  strength.  The  threads  are  introduced 
by  means  of  needles  of  different  curves :  in  some  instances  it  is  conve¬ 
nient  to  have  them  set  in  a  handle  with  the  eye  near  the  point  (nsevus 
needle),  instead  of  the  shank.  For  metallic  threads  a  slight  modification 
of  the  ordinary  needle  is  required,  to  prevent  the  wire  when  doubled  back 
after  passing  through  the  eve  from  offering  any  obstruction  to  its  passage 
through  tissues;  “tubular”  needles  are  also  employed  for  this  purpose. 

Sutures  may  be  of  various  kinds ;  but  the  one  most  commonly  had 
resort  to  in  all  cases  involving  the  integument,  is  the  interrupted,  which 
consists  of  as  many  single  stitches,  from  an  inch  to  an  inch  and  a  half 
apart,  as  may  be  necessary  to  close  the  opening.  In  longitudinal  wounds, 
the  first  stitch  should  be  inserted  in  the  centre;  but  if  there  be  any 
angles,  as  must  be  the  case  after  crucial  incisions,  the  extremities  should 
be  first  closed ;  if  more  than  one  suture  be  required,  they  should  all  be 
in  position  before  the  first  is  fastened.  This  is  effected  in  the  case  of  the 
silk  thread  by  tying  the  reef-knot,  and  in  that  of  the  wire,  by  twisting 
the  ends  round  one  another;  in  either  instance,  the  ends  are  cut  off 
short.  The  fastening  must  not  lie  over  the  line  of  incision,  but  on  one 
or  other  side  of  it.  As  to  the  time  the  suture  should  be  allowed  to 
remain,  that  must  depend  greatly  on  the  nature  and  progress  of  the 
wound ;  as  a  rule,  from  24  to  48  hours  is  sufficient ;  b}^  that  time  they 
will  have  answered  their  purpose  of  procuring  union  of  the  opposed 
surfaces.  Every  minute  they  are  left  in  after  this  is  detrimental  to 
adhesion,  and  is  attended  with  the  risk  of  the  excitation  of  undue  action. 
The  wire  suture  may,  however,  in  some  cases  be  advantageously  retained 
for  a  much  longer  period,  for  six,  eight,  or  ten  days;  but  at  last  even 
this  will  produce  ulceration.  In  withdrawing  them,  the  knot  or  twist  is 
raised  by  forceps,  and  the  thread  divided  on  one  side  of  it ;  gentle  trac¬ 
tion  on  the  knot,  the  forefinger  of  the  other  hand  being  placed  close  to 
the  point  of  exit  of  the  skin,  to  prevent  disturbance  of  the  newly  formed 
lymph,  draws  the  suture  out.  When  wire  has  been  used,  the  bends  in  it 
should  be  straightened  as  much  as  possible  before  pulling. 

In  the  continuous  suture,  or  glover’s  stitch,  the  thread  is  carried  on 
from  stitch  to  stich,  instead  of  being  detached  from  the  needle,  and 
fastened  off  as  in  the  interrupted  suture.  The  stitches  are  placed  nearer 
together,  so  that  the  adjustment  of  the  edges  is  more  intimate.  Either 
metallic  or  silk  thread  can  be  employed ;  in  withdrawing  it,  each  loop 


DRESSING  OF  INCISED  WOUNDS. 


171 


must  be  divided,  and  each  piece  removed  separately,  as  in  the  common 
stitch.  This  form  of  suture  is  not  veiy  often  emplo^’ed,  but  it  may  be 
used  in  simple  incisions  of  some  lengtli,  such  as  are  left  after  the 
removal  of  tumors  in  the  trunk,  or  are  required  for  ovariotom}’,  in 
■wounds  of  the  intestines,  etc. 

The  quilled  suture  is  employed  where  the  sides  of  a  deep  longitudinal 
wound  are  required  to  be  kept  in  contact  throughout,  as  in  ruptured 
perinseum ;  it  consists  of  a  series  of  double  interrupted  sutures  of  stout 
silk  or  whipcord  passed  deepl}^,  through  the  loops  of  which,  that  hang 
out  on  one  side  of  the  wound,  is  passed  a  piece  of  bongie,  glass  rod,  or 
quill,  whilst  the  ends  of  the  thread  are  tighth’  tied  over  a  similar  cylin¬ 
der  on  the  opposite  side.  The  stitches  should  enter  and  emerge  about 
half  an  inch  from  the  line  of  incision,  and  be  so  placed  that  the  cylinders 
when  in  situ  lie  parallel  to  one  another.  Fine  interrupted  sutures  may 
be  used  in  addition,  to  connect  the  superficial  parts. 

The  twisted  ov  figure-of-'^  suture  is  very  commonly  employed  in  surgeiy. 
A  slender  pin,  made  of  soft  iron,  with  a  steel  point,  is  introduced  through 
each  lip  of  the  wound,  at  a  distance  of  about  one-third  of  an  inch  from 
the  margins;  and  whilst  the  latter  are  held  in  contact,  a  piece  of  silk 
twist  is  passed  in  a  figure-of-8  round  the  pin,  care  being  taken  not  to  draw 
it  too  tight,  nor  to  compress  the  soft  parts  between  the  needle  and  the 
thread,  lest  sloughing  ensue.  The  projecting  ends  of  the  pin  are  now  cut 
off  with  pliers,  and  the  skin  beneath  them  protected  with  plaster.  This 
s  ture  is  invariabl}^  used  in  the  treatment  of  harelip,  but  it  is  of  great  ser¬ 
vice  wherever  the  lips  of  the  wound  are  very  vascular ;  it  has  the  advantage, 
likewise,  of  taking  the  tension  off  the  suture,  and  transferring  it  to  the 
tissues  themselves,  so  that  it  is  less  likel}"  to  cut  its  way  out  than  the 
interrupted  suture.  The  pin  ma}''  be  withdrawn  in  about 
forty-eight  hours. 

The  serrefine  (Fig.  68),  a  twisted  coil  of  silver  wire,  with 
the  extremities  terminating  in  small  hooks,  b}'  means  of 
which  the  edges  are  kept  in  contact,  may  be  had  recourse 
to  in  cases  where  veiy  accurate  union  of  the  lips  of  a  wound 
is  required,  as  in  cuts  about  the  face,  and  the  like.  The 
inventor,  Yidal  de  Cassis,  recommends  a  large  number  to 
be  used,  and  that  they  should  be  allowed  to  remain  in  twenty- 
four  hours.  They  are  made  in  sizes  one  to  six,  the  latter  being  the 
largest. 

Plasters  are  of  various  kinds,  those  most  commonly  employed  being 
the  resin,  soap,  and  isinglass  plasters.  Each  of  them  possesses  peculiar 
properties,  fitting  it  for  use  in  particular  cases.  The  resin  plaster  has 
the  advantage  of  being  most  adhesive,  and  of  not  being  readily  loosened 
by  discharge ;  but,  on  the  other  hand,  it  is  irritating,  stick}",  difficult  to 
remove,  and,  in  consequence  of  the  lead  that  it  contains,  leaves  a  dirty- 
looking  incrustation  behind  it.  The  soap  plaster  is  less  irritating,  but 
at  the  same  time  less  adhesive;  it  is  consequently  not  much  used  in  the 
management  of  wounds.  The  isinglass  plaster  is  doubtless  the  most 
cleanly  and  least  irritating  of  all,  and,  being  transparent,  permits  the 
Surgeon  to  see  what  is  taking  place  beneath  it;  but  it  is  readily  loosened 
by  the  discharges,  and  is  apt  to  run  into  a  cord. 

Whichever  variety  is  used,  the  plaster  should  be  cut  into  strips  of 
convenient  length  and  breadth,  and  heated  by  being  passed  through  hot 
water.  All  superfluous  hair  having  been  removed,  and  the  surface  well 
dried,  each  strip  should  be  laid  down  evenly  between  the  points  of 
suture,  when  these  have  been  used,  so  as  to  compress  and  support  each 


Fig.  68. 


The  Serrefine. 


172 


INJURIES  OF  SOFT  PARTS. 


side  of  the  wound  with  equal  force  ;  the  longer  the  strip,  the  firmer  will 
be  its  holding,  and  the  less  likely  it  will  be  to  be  prematurely  loosened. 
In  removing  the  plaster  both  ends  should  be  raised  at  the  same  time, 
and  the  strip  then  taken  off  -without  either  lip  of  the  wound  being 
unduly  dragged  upon.  The  strip  should  be  allowed  to  remain  undis¬ 
turbed  as  long  as  possible,  and  each  one  replaced  before  the  next  is 
removed. 

In  a  certain  class  of  incised  wounds,  of  limited  extent,  where  the 
edges  can  be  accuratel}^  adapted  to  one  another  bj'  sutures  or  plaster,  or 
by  the  combination  of  both,  and  when  but  little  oozing  is  to  be  expected, 
very  fair  union  by  scabbing  may  be  looked  for  without  an}^  further 
dressings.  Indeed,  some  Surgeons  prefer  to  treat  such  extensive 
wounds  as  amputation-stumps  in  this  way.  The  formation  of  the  scab, 
however,  may  be  hastened  and  imitated  by  the  use  of  Collodion^  painted 
freely  over  the  line  of  incision  with  a  camel’s  hair  brush,  after  the  sur¬ 
face  has  been  well  dried,  or  of  Styptic  Colloid^  which  has  the  further 
advantage  of  being  haemostatic  and  antiseptic.  The  film  thus  formed 
may  be  further  strengthened  by  some  shreds  of  charpie  or  fine  lint.  A 
second  or  third  application  of  the  collodion  or  st3q3tic  colloid  will  be 
required,  if  the  crust  show  any  sign  of  becoming  detached ;  otherwise  it 
may  be  allowed  to  remain  until  it  separates  of  itself,  which  it  usually 
does  in  the  course  of  a  few  daj’s.  Similaily,  a  piece  of  lint  soaked  in 
blood,  or  in  compound  tincture  of  benzoin,  may  be  applied  over  the 
wound,  and  under  it,  direct  cohesion  by  a  process  analogous  to  that  of 
scabbing  may  take  place. 

When  the  wound  is  more  extensive,  and  the  simple  measures  just  de¬ 
scribed  are  impracticable,  the  edges  are  to  be  covered  with  a  fold  of  lint 
moistened  in  tepid  water,  to  which  carbolic  acid  has  been  added  in  the 
proportion  of  1  to  100,  over  which  is  laid  a  piece  of  oiled  silk,  or  other 
impermeable  material,  a  trifle  larger  in  every  direction  than  the  lint 
(water-dressing),  whilst  the  whole  surface  in  the  neighborhood  is  kept 
cool  by  a  piece  of  wet  lint,  or,  if  the  inflammation  threaten  to  run  high, 
by  irrigation.  Some  surgeons  use  the  best  olive  oil  as  an  application 
in  preference  to  water,  as  being  more  soothing,  less  heating,  and  less 
prone  to  promote  decomposition  ;•  by  others,  a  solution  of  sulphurous 
acid  is  recommended  (1  part  saturated  solution  to  7  or  8  of  water). 
Carded  oakum  in  place  of  lint  has  the  advantage  of  being  highly  ab¬ 
sorbent,  cleanl}",  and  antiseptic,  but  is  of  greater  service  in  suppurating 
wounds  than  in  recent  ones.  The  first  dressings  should  be  left  unchanged 
for  two  or  three  days  ;  the  sutures  may  then  be  removed,  and  the  plas¬ 
ters  readjusted  as  thej'  become  loosened,  care  being  taken  to  support 
the  sides  whilst  doing  so.  One  important  point  in  the  management  of 
every  wound  is  to  maintain,  as  much  as  possible,  the  injured  structures 
in  a  state  of  rest.  This  is  to  be  done  by  position,  b}^  the  Surgeon  refrain¬ 
ing  from  disturbing  the  parts  unnecessarily,  using  his  eye  rather  than 
his  hand  to  judge  of  the  progress  made,  and  b^"  the  use  of  compresses 
and  bandages.  Compresses  of  soft  linen  or  lint  should  be  so  disposed 
as  to  aid  in  keeping  the  sides  in  apposition,  whilst  the}'  prevent  the  col¬ 
lection  of  fluids  in  the  recesses  of  the  wound;  the  bandages  should  be 
applied  over  them  so  as  to  exert  a  steady,  well-regulated  pressure,  but 
not  to  impede  the  free  circulation  of  blood  in  the  part.  . 

The  Antiseptic  Treatment  of  Wounds. — Allusion  has  alread}^  been 
made  at  p.  157  to  the  theory  founded  on  Pasteur’s  observations  and 
experiments  which  attributes  suppuration,  in  the  majority  of  cases,  to 
the  putrefactive  fermentation  set  up  in  an  animal  fluid  by  the  develop- 


ANTISEPTIC  TREATMENT. 


173 


merit  in  it  of  microscopic  germs  carried  into  it  through  the  medium  of 
the  atmosphere,  and  not  spontaneously  developed  in  it  any  change 
taking  place  in  the  tissues  or  fluids  of  the  part  independently  of  such 
impregnation.  According  to  the  “  Germ-Theory”  as  applied  to  wounds, 
it  necessarily  follows  that,  if  the  impregnating  germs  can  be  rigidly 
excluded  from  a  wound,  all  those  suppurative  actions  that  are  conse¬ 
quent  to  and  dependent  upon  the  implantation  of  new  organisms  on  a 
raw  surface  will  fail  to  develop  themselves.  This  may  evidently  be 
accomplished  in  two  wa3’S  ;  either  completely  excluding  all  air  from 
a  wound,  and  thus  shutting  out  the  vehicle  preventing  the  intrusion  of 
the  germs  carried  by  it ;  or  else  by  destro}dng  the  germs  floating  in 
the  air  around  the  wound  b^"  an  antiseptic  vapor,  as  of  carbolic  acid, 
and  thus  admitting  to  the  surface  of  the  wound  absolutely  pure  air 
that  has  been  entirely’’  freed  from  all  organic  or  septic  matters.  It  is 
important  to  bear  these  points  in  mind,  and  to  recollect  that  in  accord¬ 
ance  with  this  theory  the  exclusion  of  atmospheric  air  from  a  wound 
is  hy  no  means  necessary;  that  it  does  not  act  injuriously  of  itself, 
but  simph^  as  a  vehicle  of  septic  germs ;  and  that,  if  these  be  destroj^ed 
by  chemical  action  or  removed  by  filtration,  and  the  air  thus  rendered 
absolutely  and  surgically  pure,  so  far  as  organic  or  septic  intermixture 
is  concerned,  it  may  be  freel}^  admitted.  Taking  this  germ-theoiy  as  his 
starting-point.  Lister  has  founded  on  it  a  plan  of  treatment  in  wounds, 
as  novel  as  it  is  scientific  and  ingenious,  which  is  known  as  the  “  Anti¬ 
septic  Method.”  The  principle  on  which  this  treatment  is  founded 
consists  in  protecting  the  wound  in  such  a  manner,  during  the  process 
of  its  healing,  that  no  organic  germs  floating  in  the  air  are  admitted 
to  it.  This  principle  is  carried  out  in  two  ways — by  covering  the  wound 
with  antiseptic  dressings,  and  b^"  surrounding  it  W'ith  an  antiseptic  at¬ 
mosphere — the  active  agent  for  both  purposes  being  carbolic  acid. 

It  is  claimed  for  this  method  that,  when  it  has  been  thoroughly  carried 
out,  union  will  take  place  even  in  extensive  contused  and  lacerated 
wounds,  without  the  formation  of  a  single  drop  of  pus,  and  without  the 
occurrence  of  an}^  general  febrile  reaction.  The  principle  on  which 
this  method  of  treatment  is  founded,  is,  as  is  well  known,  disputed  by 
Pouchet,  Charlton  Bastian,  and  other  scientific  men,  who  advocate  the 
doctrine  of  spontaneous  generation.  It  would  be  altogether  foreign  to 
the  scope  of  this  work  to  enter  into  this  discussion ;  and  whether  the 
germ-theory  be  correct  or  not,  matters  perhaps  little  to  the  practical 
Surgeon,  for  there  can  be  no  doubt  that  the  decomposition  of  fluids  in 
wounds,  and  the  consequent  suppuration,  are  greatly  favored  by  the 
admission  of  air ;  and  that  any  treatment  which  has  for  its  basis  the 
exclusion  of  impure  air  and  the  prevention  or  arrest  of  decomposition  of 
the  animal  fluids  by  an  antiseptic,  such  as  carbolic  acid,  must  be  theo¬ 
retically  advantageous,  and  based  on  sound  principles  of  practice.  If  the 
admission  of  aiV  into  a  wound  were  the  sole  cause  of  its  suppuration, 
whether  that  result  be  the  consequence  of  the  chemical  constitution  of 
the  air,  or  of  the  introduction  into  the  wound  through  its  medium  of 
organic  particles  that  produce  a  fermentative  action  in  the  fluids  and 
tissues  in  which  they  are  deposited,  there  can  be  no  doubt  that  any^ 
method  of  treatment  having  for  its  object  the  exclusion  of  the  air  and 
the  destruction  of  these  organic  particles  ought  to  prevent  absolutely 
the  formation  of  pus  in  the  wound.  But,  as  w^e  see  suppuration  take 
place  in  subcutaneous  wounds,  and  in  other  situations  (as  boil  and 
whitlow),  into  which  no  air  has  been  admitted,  we  cannot  look  upon  the 
atmosphere  as  being  either  directly  or  indirectly  the  sole  occasioning 


174 


INJURIES  OF  SOFT  PARTS. 


cause  of  this  action,  however  much  it  ma}’^  favor  it ;  and  it  must  be 
referred  in  such  cases  to  the  influence  of  other  agencies,  amongst  which 
certain  morbid  conditions  of  the  blood,  constitutional  derangement  of  the 
patient,  and  intensity  of  inflammation  are  amongst  the  more  important 
and  direct. 

It  is  undoubtedly  these  disturbing  influences  that  prevent  the  com¬ 
plete  success  of  the  “Antiseptic  Method’’  in  a  certain  number  of  cases. 
Theoretically  it  is  perfect ;  in  practice  its  success  is  not  constant.  It 
would  be  successful  in  all  cases,  were  the  healing  of  a  wound  a  purely 
local  act  under  the  sole  influence  of  local  conditions  of  tissue  and  of 
treatment.  But  this  is  far  from  being  the  case.  The  repair  of  a  wound 
is  a  process  that  is  materially  influenced  for  good  or  for  evil  by  the  state 
of  the  patient’s  constitution.  When  that  is  healthy  and  pure  the  wound 
will  readily  heal  under  any  favorable  local  conditions,  and  under  none,  I 
believe,  more  readily  than  under  the  antiseptic  method.  When  the  blood 
is  vitiated  and  the  constitution  depraved,  no  mere  local  method  of  treat¬ 
ment  can  be  trusted  to  as  an  infallible  preventive  of  local  morbid  action. 
But  even  in  such  unfavorable  cases  as  these,  where  suppuration  and 
slough  are  rather  the  consequences  of  a  bad  constitutional  than  of  a 
morbid  local  condition,  the  antiseptic  method,  by  lessening  the  tendency 
to  decomposition  and  to  putrefactive  fermentative  changes  in  the  wound, 
and  by  rapidW  removing  and  destroying  noxious  materials  and  effluvia, 
wall  do  more  than  an}^  other  plan  of  treatment  to  limit  the  morbid  local 
action  that  results  from  the  continued  presence  in  and  around  the  wound 
of  septic  matter,  and  to  prevent  those  grave  constitutional  sequences 
that  inevitably  result  from  its  absorption  into  the  system,  and  thus  to 
avert  the  various  forms  of  blood-poisoning  that  are  frequently  occasioned 
by  wounds  in  an  unclean,  suppurating,  or  sloughy  state. 

As  the  “  germ-theory”  constitutes  the  basis  of  Lister’s  antiseptic 
method,  success  in  its  practice  can  only  be  looked  for  with  the  aid  of 
attention  to  minutiae  and  details,  and  to  extreme  care  in  manipulation. 
One  single  septic  germ  making  its  way  to  the  surface  of  the  wound 
would,  in  accordance  with  this  theory,  be  sufficient  to  light  up  all  the 
mischief  which  it  is  the  object  of  this  method  to  avert. 

The  details  of  the  antiseptic  method  have  been  most  ingeniously 
varied  from  time  to  time  by  Lister.  Any  one  who  understands  the 
principles  on  which  it  is  founded  can  have  no  great  difficulty  in  cariying 
it  out  on  the  following  plan,  which  more  or  less  modified  is  in  accord¬ 
ance  with  his  most  recent  views  on  the  subject. 

Arterial  hemorrhage,  when  present,  is  controlled  by  torsion  or  by 
tying  the  vessels  with  carbolized  ligatures  (fine  catgut  soaked  in  a  solu¬ 
tion  of  carbolic  acid  in  five  parts  of  olive  oil)  and  cutting  the  ends  off 
short,  as  the  ligature  is  to  be  allowed  to  remain  in  the  wound  to  become 
incorporated  with  the  other  tissues.  Sanious  oozing  is  to  be  checked  by 
cold  carbolized  water.  The  whole  extent  of  the  wound,  even  to  the  most 
remote  recesses,  is  next  to  be  thoroughly  mopped  or  syringed  out  with  a 
watery  solution  of  the  acid  (1  to  100)  in  cases  of  operation.  In  cases  of 
accidents  the  solution  used  must  be  1  to  20  if  some  time  have  elapsed 
since  the  accident,  or  1  to  40  if  the  wound  be  tolerablj^  fresh.  Any 
sutures  that  may  be  required  should  be  metallic  (the  needle  and  wire 
having  been  dipped  in  carbolic  acid  and  oil — 1  to  10),  or  of  carbolized 
silk  twist  steeped  in  hot  beeswax  with  one-tenth  of  carbolic  acid,  the 
needle  and  thread  being  dipped  in  the  carbolic  oil  before  use.  The 
wound  being  closed,  the  solution  is  once  more  injected  between  its  lips, 
and  the  neighboring  cutaneous  surface  washed  with  the  same,  and  the 


ANTISEPTIC  TREATMENT. 


175 


antiseptic  dressing  immediately  applied.  A  more  efficacious  method, 
having  the  advantao-e  of  surrounding  the  wound  with  a  carbolized 
atmosphere  in  which  no  germ  could  exist,  is  to  perform  the  Avhole  opera¬ 
tion  in  the  midst  of  a  spray  of  carbolic  acid  and  water  (1  to  100)  thrown 
upon  the  part  by  an  anaesthetic  spray  apparatus,  or  bj'’  two  or  more,  if 
necessary  from  the  extent  of  the  operation,  the  spray  being  continued 
without  intermission  until  the  dressing  is  applied.  If  from  any  reason 
the  spray  ceases  the  wound  must  be  instantly  covered  with  a  “guard” 
consisting  of  a  piece  of  linen  rag  soaked  in  carbolic  acid  and  water — 1 
to  100,  which  should  be  constantly  in  readiness.  In  cases  of  accident, 
the  process  of  syringing  or  mopping  out  the  wound  must  first  be  com¬ 
pleted,  and  the  spray  may  then  be  used  during  the  application  of  the 
sutures  and  completion  of  the  dressing.  If  old  sinuses  be  implicated 
in  the  operation-wound,  they  must  first  be  syringed  out  with  a  solution 
of  chloride  of  zinc  (40  grs.  to  ^j).  Before  closing  the  wound,  if  it  be  of 
an}’  considerable  size,  a  plug  of  lint  soaked  in  tlie  oily  solution,  or  a 
piece  of  the  antiseptic  gauze,  or  better  still,  a  piece  of  India-rubber 
drainage-tube,  previously  soaked  for  twenty-four  hours  in  a  concentrated 
solution  of  carbolic  acid  in  water,  must  be  inserted  at  one  angle  to  pTo- 
vide  a  certain  exit  for  the  serous  discharge,  which  is  at  first  very  abun¬ 
dant  in  consequence  of  the  irritation  of  the  carbolic  acid,  and  which,  if 
pent  up  in  the  wound,  would  cause  sufficient  irritation  to  produce  suppu¬ 
ration.  This  “drain”  may  be  removed  on  the  second  day, by  which  time 
the  discharges  will  almost  liave  ceased.  The  dressing  is  performed  as 
follows.  In  all  cases  of  wound  it  is  better  from  the  beginning  to  protect 
the  raw  surface  or  edges  of  the  wound  as  far  as  possible  from  any  direct 
contact  with  the  carbolic  acid  in  the  dressings,  which  would  infallibly 
cause  sufficient  irritation  to  produce  suppuration.  The  weak  solution 
used  on  the  protective  and  in  the  spray  during  the  dressing  is  so  tempo¬ 
rary  in  its  action  as  scarcely  to  require  consideration,  it  being  rapidly 
absorbed  by  the  tissues  as  soon  as  the  dressing  is  completed.  The 
wound  is  therefore  covered  with  a  piece  of  “protective”  (oiled  silk 
brushed  with  one  part  of  dextrine  to  two  of  powdered  starch  in  16  of 
cold  water  solution  of  carbolic  acid,  and  allowed  to  dry),  which  is  first 
dipped  ill  the  watery  solution  (1  to  100),  and  which  must  extend  at  least 
one  inch  on  all  sides  of  the  wound.  The  whole  part  for  a  distance  of  at 
least  six  inches  on  all  sides  of  the  wound  is  then  wrapped  in  the  “anti¬ 
septic  gauze”  folded  six  or  eight  layers  thick  according  to  the  amount 
of  discharge  that  may  be  expected,  and  between  the  two  superficial 
layers  must  be  put  a  piece  of  oiled  silk,  gutta-percha,  or  thin  Mackintosh 
cloth,  so  that  the  discharge  may  not  soak  through  at  one  spot  and  de¬ 
compose,  but  may  be  evenly  diffused  over  the  whole  dressing.  Over  all 
is  put  a  bandage  composed  of  the  antiseptic  gauze.  In  changing  the 
dressing  the  same  rules  must  be  observed,  and  the  wound  never  for  an 
instant  exposed  to  view  unless  under  a  spray  of  carbolic  acid  and  water. 
While  preparing  the  new  dressings,  if  it  be  inconvenient  to  maintain  the 
spray,  the  wound  must  be  covered  with  a  piece  of  rag  soaked  in  carbolic 
acid  and  water  (1  to  100).  The  same  piece  of  Mackintosh  cloth  may  be 
used  all  through  the  case,  if  it  be  washed  at  every  dressing  in  carbolic 
acid  and  water.  The  dressing  must  be  repeated  at  first  every  day,  but 
when  the  serous  discharge  has  ceased,  every  second,  third,  or  fourth  day 
will  be  suflicient  according  to  the  amount  of  discharge.  If  it  be  thought 
necessary  to  apply  .strapping  to  the  wound,  it  may  be  done  under  the 
spray,  by  dipping  the  strapping  in  a  mixture  of  one  part  of  carbolic 
acid  and  water  (I  to  20)  to  which  are  added  three  parts  of  boiling  water. 


176 


INJURIES  OF  SOFT  PARTS. 


If  no  spray-apparatus  be  at  hand  during  the  dressing,  the  same  results 
may  be  obtained  by  running  a  stream  of  carbolic  acid  and  water  from  a 
s^n-iuge,  irrigator,  or  sponge  over  the  wound,  as  the  dressing  is  removed, 
and  rapidl}^  covering  it  with  a  “guard”  of  linen  rag  soaked  in  the  same 
solution  as  described  in  the  chapter  on  the  treatment  of  abscesses. 

Injiamination  of  Incised,  Wounds. — If  union  by  the  first  intention 
fail  from  any  local  or  constitutional  cause,  inflammation  takes  place  in 
and  around  the  wound  ;  the  lips  swell  and  become  red ;  a  sero-sanguino- 
lent  discharge,  gradually  assuming  a  puriform  character,  exudes  ;  and 
at  the  same  time  a  general  febrile  state  sets  in,  attended  with  rise  of  the 
pulse  and  temperature,  heat  of  skin,  thirst,  etc.,  which  continues  until 
suppuration  is  fairly  established.  The  thermometer  will  always  give 
timely  w^arning  of  the  approach  of  this  “  primary  traumatic  fever”  by 
indicating  a  rise  of  2°  or  3°  Fahr.  The  use  of  this  instrument  in  sur¬ 
gical  practice  is  attended  with  great  advantage,  as  it  is  often  the  first 
to  indicate  the  onset  of  some  of  the  more  serious  sequelie  of  wounds 
and  injuries.  In  these  circumstances,  the  sutures  should  be  immediately 
removed;  the  strips  of  plaster,  if  continued,  should  be  used  for  support 
onl}?",  and  not  for  union ;  a  thick  piece  of  warm  water-dressing  should  be 
applied,  and  the  general  condition  of  the  patient  appropriately  treated. 
AVhen  granulations  have  sprung  up,  and  suppuration  has  fairlj^  set  in, 
the  treatment  must  be  conducted  in  accordance  wdth  those  general 
principles  that  guide  us  in  the  management  of  ulcerated  surfaces 
(pp.  147  and  149).  The  suppuration  must  be  moderated,  the  process 
of  cicatrization  facilitated  by  the  application  of  a  bandage,  the  general 
health  attended  to,  and  the  strength  of  the  patient  supported.  With 
the  view  of  stimulating  the  granulations  to  cicatrize,  and  to  check  the 
formation  of  pus,  the  carbolized  water-dressing  may  be  replaced  by 
lotions  of  sulphate  of  zinc  (2  gr.  to  the  ounce),  sulphocarbolate  of 
zinc  (3  or  4  grains  to  the  ounce),  lime-water,  etc.  If  any  tendency  to 
ulceration  or  formation  of  sloughs  be  met  with,  a  wash  of  nitric  acid 
and  opium  (extracti  opii  gr.  v.,  acidi  nitrici  dil.  m.  x.  to  the  ounce),  or 
lotions  of  iodine,  sulphite  of  potash,  or  chloride  of  zinc,  of  requisite 
strength ;  in  the  latter  case,  the  deeper  parts  of  the  wound  should  be 
well  syringed  out  wdth  the  lotion.  When  the  granulations  are  high, 
pale,  and  flabb}^  they  should  be  rubbed  down  with  sulphate  of  copper, 
or  touched  freely  with  solid  nitrate  of  silver. 

An  intercurrent  attack  of  traumatic  inflammation  will  at  once  put  a 
stop  to  the  process  of  union;  the  parts  around  become  swollen,  hot, 
and  painful,  the  formation  of  pus  ceases,  the  wound  is  dry  and  angry 
looking,  and  portions  of  it  already  healed  open  up  once  more.  Hot 
fomentations  or  warm  emollient  poultices  should  be  applied  until  sup¬ 
puration  is  reestablished,  when  they  may  be  replaced  by  cooling  lotions 
and  cold  compresses;  when  all  signs  of  inflammation  have  passed,  the 
granulating  surfaces  may  be  again  brought  together  b}^  sutures,  plasters, 
and  bandages,  with  a  view  of  their  uniting  by  “secondary  adhesion.” 
On  the  other  hand,  should  the  inflammation  run  on  to  gangrene,  the 
separation  of  the  sloughs  must  be  accelerated  by  poultices,  whilst  the 
powers  of  the  patient  are  sustained  by  liberal  diet,  with  the  free  admin¬ 
istration  of  stimulants.  Putrefaction  and  fetor  must  be  combated  by 
the  use  of  lotions  containing  carbolic,  chlorous,  or  sulphurous  acids, 
iodine,  bromine,  Condy’s  fluid,  etc. 

In  very  severe  cases  of  traumatic  inflammation,  especially  in  wounds 
implicating  the  joints,  compression  or  ligature  of  the  main  trunk  leading 
to  the  seat  of  injuiy  has  been  practised,  with  the  object  of  limiting  the 


CONTUSED  AND  LACEEATED  WOUNDS. 


177 


quantity  of  blood  in  the  tissues,  and  regulating  the  circulation  through 
them,  so  that  the  processes  of  repair  can  be  more  rapidly  entered  on. 
For  further  remarks  on  this  subject,  the  reader  is  referred  to  page  113. 

Faulty  Cicatrices  may  give  rise  to  much  disfigurement  from  excessive 
or  irregular  contraction  ;  and  various  plastic  operations,  which  will  be 
described  more  fully  hereafter,  are  recorded  to  remedy  this  inconveni¬ 
ence.  Much  benefit  will  occasionallv  result  from  excising  the  cicatrix 
and  then  bringing  together  the  opposite  edges  of  the  wound  in  a  uni¬ 
form  smooth  line.  Should  it  be  too  large  for  this,  if  flat  it  must  be 
less — if  angular,  as  the  flexum  of  a  joint,  it  may  be  divided  down  to 
the  sound  structures  beneath,  and  the  gap  thus  left  filled  by  a  flap  of 
integument  dissected  from  the  neighboring  parts  and  twisted  into  it. 
Again,  in  certain  situations  on  the  trunk,  the}’  will  yield  before  the 
pressure  of  the  viscera  and  thus  give  rise  to  hernim.  In  some  cases 
they  remain  weak,  thin,  and  tender  for  a  considerable  period,  with  con¬ 
stant  tendency  to  break  down  again  ;  these  are  generall}’  due  to  consti¬ 
tutional  causes.  They  ma}’  also  become  painful,  or  be  the  seat  of 
pigmental’}^  deposits.  In  other  rare  instances  they  undergo  a  species 
of  hypertrophy  of  a  non-malignant  character,  chiefl}"  met  with  after 
burns,  which  is  called  spurious  or  AliberFs  keloid^  to  distinguish  it 
from  true  keloid,  that  does  not  attack  scars.  This  condition  may  call 
for  surgical  interference,  but  it  often  disappears  spontaneousl}^ 

Contused  and  Lacerated  Wounds. — These  may  be  defined  to  be 
w’ounds  that  are  conjoined  with  more  or  less  bruising  about  the  edges 
and  sides ;  presenting  every  possible  variety  in  the  degree  of  con¬ 
tusion  and  of  wound,  from  a  cut  on  the  shin  to  a  limb  crushed  and 
lacerated  by  a  cannon-shot.  The}^  are  commonly  inflicted  by  blunt 
cutting  instruments,  as  by  a  hatchet,  or  by  stones,  bludgeons,  etc. 
Lacerations  by  machinery,  in  which  parts  are  torn  off  or  crushed,  the 
bites  and  gorings  of  animals,  and  gunshot  injuries  of  all  kinds,  come 
under  this  denomination. 

Characters. — Whatever  their  mode  of  infliction,  these  wounds  present 
certain  characters  in  common,  b}"  which  they  differ  from  all  other  inju¬ 
ries.  Their  lips  are  irregular  and  torn,  less  gaping  than  incised  wounds, 
but  surrounded  by  more  or  less  ecchymosis  and  contusion,  with  a  ten¬ 
dency  to  slough  at  their  sides.  There  is  usually  but  little  hemorrhage, 
and  the  pain  is  of  an  aching  or  dull  character.  In  consequence  of  the 
sloughy  state  of  the  lips  and  sides,  these  wounds  almost  alwa5^s  unite 
by  the  second  intention. 

Contused  and  lacerated  wounds  present  peculiarities  according  to  the 
mode  of  their  infliction. 

When  they  are  occasioned  b}^  the  bite  of  a  large  animal,  the  part 
injured  becomes  very  painful,  and  inflames  extensively;  the  wound  being 
lacerated,  much  contused,  and  often  penetrating  deeply.  It  sloughs  in 
consequence  of  the  pressure  to  which  it  has  been  subjected,  and  of  the 
animal  having  shaken  and  torn  the  part  seized.  When  the  wound  is 
inflicted  b}’  the  tusk  or  horn  of  an  animal,  it  is  extensively  lacerated 
rather  than  contused,  and  often  partakes  of  the  nature  of  a  punctured 
w’ound. 

When  a  part  of  the  body  is  torn  off,  the  wound  presents  peculiar 
characters  ;  which  differ,  however,  according  as  the  separation  is  effected 
at  the  part  struck  or  seized,  or  at  a  distance  from  it. 

In  the  first  case — as  when  a  cannon-ball  carries  off  a  limb,  or  an  arm 
is  caught  in  a  steam-mill  or  rag-tearing  machine  and  crushed  or  torn 
off' — the  stump  presents  a  verj’  ragged  surface,  the  skin  being  stripped 
VOL.  I. — 12 


178 


INJUEIES  OF  SOFT  PAKTS. 


away  higher  than  the  other  parts,  the  tendons  hanging  out,  and  the 
bellies  of  the  muscles  that  are  torn  across  being  swollen,  protruding, 
and  apparentl3"  constricted  by  the  lacerated  integument.  A  most 
important  condition  in  such  wounds  is  the  state  of  the  vessels;  these 
are  separated  lower  down  than  the  other  parts,  for,  being  elastic,  the^^ 
elongate  and  pull  out  before  they  give  way.  There  is  no  hemorrhage, 
because  the  inner  and  middle  coats  of  the  artery,  breaking  olf  short, 
retract  and  contract  to  a  small  aperture,  and  allow  the  external  one  to 
be  dragged  down  and  twisted  over  its  mouth,  in  such  a  wa}”  as  to  offer 
a  comj^lete  barrier  to  the  escape  of  blood.  The  bone  is  crushed  off  at 
the  end  of  the  stump,  of  which  it  forms  the  irregular  conical  apex,  and 
is  often  split  up  to  the  next  joint  above. 

Occasionally",  when  parts  are  pulled  off,  they  are  separated  at  a  dis¬ 
tance,  from  the  point  seized.  Thus,  fingers  that  have  been  torn  off  b\^ 
machinery"  have  their  extensor  tendons  separated  higher  up,  at  their 
junction  with  the  belly-  of  the  muscle,  and  not  at  the  part  seized;  the 
tendon  being  drawn  out  of  its  sheath,  and  hanging  on  to  the  separated 
end  in  a  ribbon-like  manner.  In  railway"  accidents,  when  a  train  has 
l)assed  over  a  limb  without  completely  separating  it,  the  muscle's  may 
be  found  detached  from  their  orioius. 

In  the  Progress  of  a  contused  or  lacerated  wound  there  arc  two  dis¬ 
tinct  periods:  1,  that  of  the  Separation  of  the  Slough  produced  by  the 
contusion ;  and  2,  that  of  Kepair  by  Granulations  of  the  chasm  left. 
These  processes  are  analogous  to  those  which  occur  in  ulceration,  and 
arc  fully  described  at  pages  144  and  154. 

The  Extent  of  the  Slough  depends  not  only  upon  the  extent  and 
severity,  but  also  upon  the  situation  of  the  injury.  If  the  parts  around 
the  wound  be  much  bruised,  then  superficial  sloughing  to  a  great  extent 
may  occur;  if  the  wound  be  deep  though  not  extensive,  there  will  always 
be  danger  of  troublesome  sloughing,  leading  to  deep  suppuration  and 
burrowing  of  matter,  and  in  some  cases  to  secondary"  hemorrhage.  Those 
W"Ounds  that  are  situated  immediately"  over  bony  points — as  the  skin  and 
elbow — are  especially  tedious,  as  the  slough  frequently  implicates  the 
fasciae.  The  scalp  has  a  less  tendency  to  slough  than  any  other  part  of 
the  cutaneous  surface.  This  is  owing  to  its  great  vascularity",  and  to  the 
large  supply"  of  blood  which  it  receives  from  closely  subjacent  arteries. 
In  all  cases  of  contused  and  lacerated  wounds — more  especially  in  those 
of  the  scalp — there  is  great  danger  of  the  supervention  of  ery-sipelas,  and 
more  probably"  of  pyaemia. 

But  the  chief  danger  to  be  apprehended  in  wounds  of  this  description 
is  the  supervention  of  Traumatic  Gangrene^  which  may"  occur  in  three 
ways. 

1.  The  contusion  alway's  kills  a  thin  lay-er  of  tissue,  which  forms  a 
slough  on  the  sides  or  lips  of  the  wound  ;  but  in  some  cases  the  violence 
done  to  the  part  is  so  great  as  directly"  to  kill  its  whole  substance. 
Thus,  if  a  limb  be  crushed  to  a  pulp  by  machinery",  or  by  the  passage  of 
a  heavy"  wagon  over  it,  all  circulation  is  completely"  and  at  once  arrested, 
the  vitality"  of  the  part  is  destroyed  outright,  and  it  will  speedily  fall 
into  a  state  of  putrefactive  decomposition,  with  all  the  usual  signs  of 
advanced  mortification.  If  the  violence  be  not  quite  so  great  as  this, 
the  vitality"  of  the  part  may  be  lessened  and  its  resisting  power  dimin¬ 
ished  to  such  an  extent,  that  the  inflammation  necessary"  for  the  repair 
of  the  injury-  terminates  in  gangrene.  This  is  a  local  traumatic  mortifi¬ 
cation,  evincing  no  disposition  to  spread  bey"ond  the  part  injured,  but 
being  bounded  by  a  line  of  demarcation  along  which  it  will  separate.  It 


TRAUMATIC  GANGRENE. 


179 


is  not  alwa3^s  eas}^  to  distinguish  this  direct  form  of  gangrene  from  such 
discoloration  and  disorganization  of  a  limb,  as  is  still  compatible  with 
life.  In  all  cases  of  doubt  the  Surgeon  must  wait,  and  a  very  short 
time — a  few  hours — will  be  sufficient  to  declare  wdiether  the  vitality  of 
the  part  can  be  maintained  or  not.  In  cases  of  much  doubt  an  incision 
might  be  made  into  the  part,  and  the  true  state  of  things  thus  ascer¬ 
tained  ;  but  this  should  not  be  done  if  it  can  be  possibly"  avoided. 

2.  The  injury  ma3"  be  chiefly  inflicted  upon  the  great  vessels  of  the 
limb,  damaging  them  to  such  an  extent  as  to  interrupt  completel3^  the 
circulation;  gangrene  being  thus  induced  indirectl3^  in  the  parts  supplied 
b3^  them.  This  form  of  gangrene  w^e  shall  have  occasion  to  treat  of  full3^ 
when  speaking  of  the  Injuries  of  the  Arteries. 

3.  The  true  traumatic  or  “  spreading  gangrene,”  the  most  fatal  variet3^ 
of  mortification,  is  most  commonl3"  the  result  of  severe  contused  and 
lacerated  'wounds  particularl3'  wdien  complicated  with  fractures.  It  has 
a  tendency  to  spread  rapidl3%  especiall3^  through  the  areolar  planes  of 
the  limb,  often  involving  the  wdiole  member  in  less  than  twelve  hours 
after  its  invasion. 

The  true  Spreading  Traumatic  Gangrene  is  invariably  of  the  dark  and 
humid  kind.  In  it,  death  of  the  tissues  and  their  putrefaction  are  con¬ 
temporaneous.  The  putrefactive  process  does  not  take  place  in  this,  as 
in  the  other  varieties  of  gangrene  just  described,  some  hours,  or  da3^s 
even,  after  the  cessation  of  vitalit3"  in  the  part;  but  the  purplish-black 
color,  the  fetid  odor,  and  the  development  of  gas,  occur  at  the  moment 
of  the  death  of  the  tissues,  and  are  evidentl3^  dependent  on  some  peculiar 
septic  condition  of  the  parts  attacked  b3"  the  disease.  It  differs  from  the 
other  varieties  of  gangrene  in  having  no  disposition  to  limit  itself  b3^  a 
line  of  demarcation,  as  well  as  in  the  rapidity  of  its  extension  and  the 
speedy  putrescence  that  occurs  in  the  part  attacked. 

The  Causes  of  this  form  of  traumatic  gangrene  are  local  and  constitu¬ 
tional  combined.  The  Local  Causes  consist  of  injuries,  more  particularl3’' 
contused  and  lacerated  wounds  of  the  hand  or  foot.  As  a  general  rule 
it  ma3",  perhaps,  be  stated  that  the  more  severe  forms  of  injury  of  this 
description,  more  especially  such  as  implicate  joints  or  bones,  are  more 
liable  to  be  followed  b3^  this  form  of  gangrene ;  but  it  w^ould  be  an  error 
to  suppose  that  severe  injuiy  is  a  necessaiT  precursor  of  it.  Compara- 
tivel3^  slight  injuries,  provided  the3"  be  of  the  nature  of  lacerated  wounds, 
have  not  unfrequentl3^  been  the  occasioning  cause  of  traumatic  gangrene 
of  the  w’orst  form.  Another  MS'ny  in  which  traumatic  gangrene  is  pro¬ 
duced  is  by  the  engorgement  of  the  tissues,  and  consequent  strangula¬ 
tion,  by  effusion  of  serous  fluid  into  the  intermuscular  planes  of  the 
areolar  tissue. 

The  Constitutional  Condition  of  the  patient  is  undoubtedl3’  the  main 
cause  of  the  supervention  of  spreading  traumatic  gangrene.  However 
severe  an  injuiy  ma3’’  be,  and  however  certainl3^  it  ma3'  kill  those  tissues 
or  that  part  of  a  limb  which  are  directl3’'  and  immediatel3^  exposed  to 
the  operation  of  the  external  violence,  the  rapidly  spreading  form  of  the 
disease  wdll  not  supervene  unless  the  constitution  be  in  an  unsound 
state ;  and  this  remark  applies  necessarily  wdth  especial  force  to  its 
occurrence  after  the  slightest  forms  of  injuiy.  The  supervention  of 
spreading  traumatic  gangrene  will  occur  in  circumstances  similar  to 
those  which  dispose  of  pyaemia,  eiysipelas,  or  sloughing  phagedaena; 
and,  in  fact,  to  the  low  and  diffused  inflammations  generall3\  They 
consist  of  imperfect  and  faulty  hygienic  conditions,  and  an  impure  state 
of  the  blood,  arising  either  from  long-continued  exposure,  antecedent  to 


180 


INJUEIES  OF  SOFT  PARTS. 


the  injuiy,  to  such  conditions,  or  from  chronic  disease  of  the  eliminatoiy 
organs,  more  particularly  of  the  kidneys.  Defective  depuration  of  the 
blood,  consequent  on  chronic  kidney-disease,  is  a  most  fertile  cause  of 
this  as  of  the  other  forms  of  gangrene.  Indeed,  I  believe  that  the  true 
spreading  traumatic  gangrene  cannot  occur  unless  the  blood  be,  pre- 
vioudy  to  the  receipt  of  the  injury,  in  a  depraved  and  disordered  state, 
the  result  of  the  conditions,  singly  or  combined,  above  mentioned. 
Hospital  miasmata,  and  exposure  to  faulty  hygienic  conditions  after  the 
receipt  of  the  injury,  do  not  appear  to  me  to  exercise  so  marked  an 
influence  on  the  occurrence  of  this  form  of  gangrene  as  of  the  low  inflam¬ 
matory  diseases  of  the  erysipelatous  type.  In  fact,  the  patient  is  rarel}', 
if  ever,  exposed  to  these  influences  sufficiently  long  after  the  occurrence 
of  the  injury  for  them  to  have  much  effect  on  his  constitutional  con¬ 
dition,  had  that  been  in  a  sound  state  previously.  Spreading  traumatic 
gangrene  occurs  only  in  recent  wounds,  and  usually  manifests  itself 
within  the  first  three  days  after  their  occurrence,  whilst  the}'  are  still  in 
their  first  stage,  and  before  suppurative  inflammation  has  set  in.  When 
once  this  has  occurred,  and  especially  if  the  wound  be  granulating,  the 
patient  ma}^  get  erysipelas,  or  pyaemia,  or  sloughing  phagedaena;  but  he 
will  no  longer  be  susceptible  of  the  spreading  form  of  traumatic  gan¬ 
grene.  I  cannot,  therefore,  but  look  upon  this  formidable  disease  as  a 
truly  constitutional  affection,  depending  more  upon  tlie  state  of  the  pa¬ 
tient’s  blood  at  the  time  of  the  reception  of  the  injury,  than  upon  the 
severity  of  that  injury,  or  upon  the  circumstances  to  which  he  has  been 
exposed  immediately  after  the  receipt  of  it. 

The  Symptoms  are  as  follow.  The  wounded  limb  at  the  seat  of  injury 
swells,  with  some  dusky  redness,  and  a  deep-seated,  tensive,  burning  pain. 
The  swelling,  redness,  and  tension  spread  upwards,  and  are  speedil}-  fol¬ 
lowed  by  a  dusky  purplish  tint,  by  a  soft  doughy  feeling  of  the  parts, 
and  in  the  course  of  a  few  more  hours  by  a  deep  blackish-purple  dis¬ 
coloration,  which  spreads  uniformly  and  with  great  rapidity  through  all 
the  tissues  affected.  This  is  accompanied  or  immediately  followed  by 
cmph3^sematous  crackling  from  gases,  the  result  of  putrefaction,  which 
are  developed  in  the  parts  attacked  by  the  gangrene.  The  changes, 
wdiich  are  of  a  putrefactive  nature,  first  develop  themselves  in  the  wound 
itself,  and  speedily  extend  from  it  to  the  surrounding  parts.  That  por¬ 
tion  of  the  limb  which  is  below  the  gangrened  part  becomes  pale,  cold, 
and  oedem  atous.  The  portion  which  is  above  becomes  rapidly  infiltrated  by 
serous  exudation,  which  runs  up  the  inner  side  of  the  limb  to  the  axilla 
or  groin,  as  the  case  may  be.  The  part  immediately  above  the  limit  of 
the  tissues  that  are  actually  mortified  is  greatly  swollen  by  oedematous 
infiltration,  tense  and  pitting  slightly,  usuall}^  mottled  in  color  of  shades 
of  greenish  or  grayish  3'eilow,  like  a  bruise  that  is  passing  oflf.  The 
■oedema  and  peculiar  discoloration  extend  higher  along  the  inner  side  of 
the  limb,  where  it  always  first  reaches  the  trunk.  Einph3^sematous 
crackling  rapidl}^  spreads  itself  along  the  same  parts,  and  the  gangrene 
here  travels  with  great  rapidit}',  hopelessly  involving  the  tissues  and 
entering  into  the  areolar  i)lanes  of  the  axilla  or  groin  in  a  veiy  few 
hours.  As  the  gangrene  advances,  the  parts  afl'ected  fall  into  a  soft, 
pulpy,  black  mass. 

On  making  an  incision  into  the  parts  so  affected,  it  w'ill  be  found  that 
the  gangrenous  disorganization  is  primarily  seated  in  the  areolar  planes 
of  the  limb,  and  that  the  muscles  are  not  affected  in  the  first  instance. 
It  will  also  be  observed  that  the  disease  extends  itself  through  the  are¬ 
olar  tissue,  the  skin  falling  secondarily  into  slough. 


TKEATMENT  OF  CONTUSED  WOUNDS. 


181 


The  constitutional  symptoms  are  throughout  of  the  lowest  ataxic 
type;  and  death  almost  invariably  ensues  in  three  or  four  days  after  the 
invasion  of  the  disease,  and  always  very  shortly  after  the  gangrene  has 
reached  the  trunk. 

Treatment  of  Contused  and  Lacerated  Wounds. — In  the  treatment  of 
the  slighter  form  of  these  injuries,  we  must  bear  in  mind  the  occurrence 
of  the  two  distinct  periods  :  1,  that  of  sloughing  ;  and  2,  that  of  granu¬ 
lation.  There  is  also  in  all  injuries  of  this  description  a  special  tendency 
to  the  occurrence  of  erysipelas  and  allied  diseases. 

Care  must  be  taken  to  clean  the  parts  thoroughly  from  foreign  bodies 
that  are  frequently  impacted  or  ground  into  them.  However  contused 
and  torn  a  flap  of  skin  may  be,  it  should,  as  a  general  rule,  never  be 
separated,  provided  it  maintain  any  attachment  to  the  neighboring  tis¬ 
sues,  but  should  always  be  replaced  on  the  chance  of  its  vitality  being 
preserved.  If  it  live,  as  it  will  often  do,  especially  about  the  scalp,  under 
apparently  the  most  discouraging  circumstances,  much  will  be  gained; 
if  it  slough,  no  harm  can  result  from  the  attempt  to  preserve  it.  There 
are  even  cases  on  record  in  which  parts  that  have  been  completely  sepa¬ 
rated  have  become  attached,  by  being  immediately  reapplied  to  the  sur¬ 
face  from  which  they  had  been  torn.  Whether  this  be  actually  the  case 
or  not,  it  is  at  all  events  certain  that  a  very  small  tongue  of  skin  is 
sufficient  to  maintain  the  vitality  of  the  part.  This  we  see  exemplified 
in  the  operation  for  the  restoration  of  a  lost  nose ;  and  cases  have  oc¬ 
curred  to  me  in  which  the  nose,  nearly  cut  off,  being  only  retained  by  a 
portion  of  one  ala,  has  readily  united  on  being  replaced :  so  likewise,  in 
bad  cases  of  compound  dislocation  of  the  fingers,  the  part  has  been  saved, 
though  merely  attached  by  a  narrow  bridge  of  skin.  After  a  part  has 
been  replaced  in  this  way,  it  should  be  retained  in  situ,  by  a  few  points 
of  interrupted  suture,  with  a  piece  of  lint  soaked  in  collodion  applied  to 
the  line  of  wound.  Tlie  sutures  must  be  left  in  for  a  somewhat  longer 
time  than  usual,  until  good  union  has  resulted.  The  hemorrhage,  as 
before  mentioned,  is  as  a  rule  easily  controlled  ;  position,  application  of 
cold,  and  the  subsequent  bandaging  being  sufficient  in  the  majority  of 
cases.  When,  however,  the  blood  is  bright-colored  and  continues  to  drip 
from  the  wound,  a  vessel  of  some  size  has  been  divided  :  this  should 
be  searched  for,  and  the  opening  closed  by  torsion  or  ligature. 

In  ordinaiT  cases  of  contused  or  lacerated  wounds,  whether  superficially 
extensive  or  deep,  we  must  facilitate  the  separation  of  the  sloughs  b}^  the 
application  of  warmth  and  moisture,  which  also  serve  to  subdue  local 
inflammation.  Carded  oakum,  moistened  in  hot  water  and  covered  with 
oiled  silk,  answers  this  purpose  better  than  poultices :  it  is  cleaner  and 
more  readily  applied,  soaks  up  the  discharges,  and  is  to  a  certain  extent 
antiseptic. 

Disinfectants  should  be  freely  used  in  all  contused  and  lacerated 
wounds.  They  must  be  washed,  syringed,  or  sprayed  out  several  times 
a  day  with  weak  solution  of  the  chlorides,  of  the  permanganates  or  of 
carbolic  acid.  In  this  way  sloughs  and  decomposed  pus  maybe  removed, 
and  the  tendency  to  local  inflammation  of  an  erysipelatous  character,  and 
the  development  of  pyaemia,  averted.  There  is  no  more  fertile  cause  for 
these  disastrous  effects  than  the  retention  of  fetid  decomposing  pus 
amongst  the  areolar  tissue  of  a  contused  wound.  It  is  in  this  class  of 
wounds  that  the  antiseptic  treatment  has  met  with  its  greatest  success. 
Under  its  use,  union  has  taken  place  in  very  extensive  injuries,  loss  of 
substance  being  replaced  by  granulations ;  the  crashed  and  torn  tissues, 
which  would  otherwise  have  probably  sloughed  off,  appearing  to  become 


182 


INJUEIES  OF  SOFT  PARTS. 


revitalized :  and  all  this  has  occurred  without  aii}^  general  febrile  dis¬ 
turbance,  and  Avith  the  loss  of  but  a  small  quantity  of  serous  fluid  in  the 
shape  of  discharge.  But,  valuable  as  the  antiseptic  treatment  incon- 
testabl}^  is  in  man}"  of  these  cases,  it  may  occasionally  fail  in  preventing 
suppuration.  Should  this  happen,  all  plasters  and  tight  and  obstructive 
dressings  must  at  once  be  removed,  so  as  to  allow  a  free  exit  of  the  dis¬ 
charges  from  the  wound.  If  this  precaution  be  neglected,  the  most  dis¬ 
astrous  consequences,  local  and  constitutional,  will  ensue  from  the  reten¬ 
tion  and  infiltration  of  the  pus  and  decomposing  material  in  the  texture 
of  the  limb  or  part. 

About  the  period  at  which  the  slough  begins  to  be  loosened,  there  is 
danger  of  the  occurrence  of  hemorrhage,  if  a  large  artery  have  been  im¬ 
plicated  in  the  injury.  When  hemorrhage  occurs  in  this  way,  it  usually 
sets  in  from  the  sixth  to  the  twelfth  day,  and  m.ay  be  speedily  fatal ;  its 
treatment  will  be  the  same  as  that  to  be  hereafter  described  for  secondary 
hemorrhage  after  ligature  of  an  artery  in  its  continuity.  After  the  sloughs 
have  separated,  an  ulcer  is  left,  which  must  be  treated  on  general 
principles. 

Amputation. — In  the  more  severe  cases  of  contused  or  lacerated 
wounds,  any  attempt  at  saving  the  part  may  be  hopeless,  and  the 
patient’s  only  chance  lies  in  amputation.  In  determining  the  expediency 
of  operation,  two  questions  present  themselves  :  1,  the  nature  of  the 
cases  in  which  amputation  should  be  performed  ;  and  2,  the  time  at 
which  it  should  be  done,  whether  immediately  after  the  infliction  of  the 
injury,  or  subsequent!}". 

It  is  difficult  to  lay  down  more  than  very  general  rules  as  to  the  hind 
of  cases  that  require  amputation  ;  much  depending  on  the  age,  constitu¬ 
tion,  and  previous  habits  of  the  patient.  In  all  cases  the  Surgeon  should 
be  careful  not  to  condemn  a  limb  that  admits  of  a  fair  chance  of  being 
saA"ed  ;  and,  if  the  patient  should  happen  to  die,  as  he  often  may,  from 
the  after-effects,  such  as  erysipelas  or  phlebitis,  of  a  contused  wound  that 
admits  of  a  fair  prospect  of  recovery,  the  Surgeon  may  justly  console 
himself  Avith  the  reflection  that,  with  the  constitutional  disposition 
leading  to  these  diseases,  the  injury  inflicted  by  the  amputation  would 
in  all  probability  have  been  equally  fatal,  and  that  thus  the  patient  has 
been  saved  the  pain  of  an  operation  that  Avould  haA"e  been  unsuccessful 
in  its  result. 

As  a  general  rule,  severe  injuries  are  more  readily  recovered  from  in 
the  young  than  in  the  old,  their  vitality  and  elasticity  of  constitution 
being  greater,  with  less  tendency  to  consecutiA"e  diseases.  Much  will 
depend  upon  the  habits  of  the  patient,  or  upon  the  existence  of  visceral 
disease  at  the  time  of  the  injury.  In  persons  who  have  been  free  livers, 
and  who  have  that  peculiar  irritability  of  system  conjoined  Avith  defi¬ 
cient  power  so  commonly  observed  in  such  subjects,  and  more  especially 
if  there  be  already  existing  disease  of  the  liver  or  kidneys,  contused 
and  lacerated  wounds  are  apt  to  be  followed  by  the  worst  forms  of  ery¬ 
sipelas  and  traumatic  gangrene,  and  thus  to  be  speedily  fatal.  Injuries 
of  the  upper  extremity  are  less  serious  than  those  of  the  lower;  its 
supply  of  blood  being  proportionably  greater  and  more  uniforinly  dis¬ 
tributed.  In  some  badly  contused  wounds^  also,  of  the  arm  and  hand, 
as  in  bad  lacerations  Avith  fracture  about  the  shoulder,  elbow,  or  meta¬ 
carpus,  resection  of  the  injured  part  may  be  performed  instead  of  amj^u- 
tation  of  the  limb. 

Though  there  may  ahvays  be  this  doubt  as  to  the  cases  that  should 
not  be  amputated,  there  are  certain  conditions  in  which  the  Surgeon 


CASES  REQUIRING  AMPUTATION. 


183 


need  never  hesitate  to  perform  this  operation,  as  the  only  chance  of 
saving  the  patient’s  life.  The  following  are  the  cases  of  severe  contu¬ 
sion  and  laceration  in  which  the  limb  should  be  amputated;  either  with 
the  view  of  preventing  the  occurrence  of  gangrene,  or  in  order  to  remove 
a  mortified  part  from  the  body,  and  thus  to  save  the  life  of  the  patient 
at  the  expense  of  the  injured  limb. 

1.  If  a  limb  have  been  torn  off  by  machinery,  carried  away  by  a 
cannon-ball,  or  cut  off  by  the  passage  of  a  railway-train  over  it,  the 
irregular  and  conical  stump  should  be  amputated,  so  as  to  leave  a  more 
useful  and  healthy  one  to  the  patient. 

2.  If  the  whole  thickness  of  a  limb — the  soft  parts  and  the  bones — be 
thoroughly  disorganized  and  crushed,  it  must  be  remov^ed. 

3.  If  the  soft  parts  be  extensively  stripped  away  from  the  bones, 
though  these  be  entire,  so  much  sloughing  and  suppuration  would  ensue 
as  to  leave  a  useless  limb,  and  amputation  should  be  performed.  It  is 
in  these  cases  that  it  is  often  especially  difficult  to  estimate  the  amount 
of  injuiy  that  cannot  be  recovered  from,  this  depending  so  much  upon 
the  age  and  constitution  of  the  sufferer.  I  believe  that  Surgeons,  in 
their  anxiety  to  save  a  limb,  often  lose  a  patient  under  these  circum¬ 
stances.  I  liave  more  than  once  had  reason  to  regret  having  attempted 
to  save  limbs  injured  in  this  way;  and  believe  that,  if  the  skin  of  the 
lower  extremity  be  extensively  torn  down  and  the  muscles  much  lace¬ 
rated,  so  as  to  slough  away,  there  is  but  little  chance  for  the  patient — 
unless  he  be  very  young,  and  of  a  remarkabl}"  sound  constitution — ■ 
except  in  amputation.  In  the  upper  extremity  it  is  different ;  there, 
recovery  may  take  place  under  the  most  adverse  circumstances. 

4.  So  also,  if  the  knee  be  largely  opened,  with  laceration  of  the  soft 
parts  and  perhaps  fracture  of  the  contiguous  bones,  the  limb  must  be 
amputated.  Corresponding  injuries  of  the  ankle,  shoulder,  and  elbow- 
joints,  may,  as  has  already  been  stated,  admit  of  resection  rather  than 
of  amputation. 

5.  Bad  crushes  of  the  foot  have  a  great  tendency  to  run  into  gan¬ 
grene,  and  hence  require  amputation.  In  the  hand,  on  the  contraiy, 
veiy  extensive  injuries  are  often  recovered  from,  without  this  operation 
being  necessary ;  and  in  many  cases  partial  resection  may  be  substituted 
for  it. 

6.  In  those  cases  in  which  a  large  artery,  as  the  femoral,  is  lacerated 
at  the  same  time  that  the  soft  parts  are  extensively  injured,  and  the 
bone  fractured,  amputation  is  required  in  order  to  prevent  the  occur¬ 
rence  of  gangrene.  In  the  more  local  form  of  traumatic  gangrene,  in 
which  the  disease  is  confined  to  the  part  directly  crushed  and  injured, 
no  good  can  come  of  dela}^,  and  amputation  should  be  performed  as  soon 
as  mortification  has  declared  itself ;  and  the  limb  must  be  removed  at 
a  sufficient  distance  from  the  seat  of  mischief.  Thus,  if  gangrene  of 
the  foot  or  ankle  come  on  in  consequence  of  a  smash  of  these  parts,  the 
upper  part  of  the  leg  or  the  thigh  in  its  lower  part  should  be  amputated. 
When  the  mortification  results  indirectly  from  injury  of  the  vessels, 
the  limb  should  also  be  immediately  removed  in  a  line  wdth  the  wound, 
unless  this  be  too  high  up ;  then  the  most  favorable  point  must  be  seized, 
as  will  hereafter  be  explained.  Amputation  in  these  circumstances  is 
by  no  means  a  very  unfavorable  operation  (and  it  is  one  that  I  have 
several  times  successfully  performed),  provided  it  be  done  sufficiently 
early,  before  the  constitution  becomes  poisoned  by  the  absorption  of 
morbid  matters  from  the  gangrenous  limb.  It  is  scarcely  necessary  to 
Tvarn  the  Surgeon  to  be  certain  of  the  existence  of  gangrene  before  he 


184 


INJURIES  OF  SOFT  PARTS. 


/ 

operates ;  and  also  that  it  be  not  a  mere  limited  slough,  but  sufficiently 
extensive  to  jeopardize  the  patient’s  life. 

7.  In  those  cases  in  which  the  true  traumatic  or  rapidly  spreading 
variety  of  gangrene  is  wholly  or  in  part  due  to  strangulation  ,  of  the 
tissues  by  serous  extravasation  into  the  areolar  planes,  much  benefit 
may  be  anticipated,  and  the  further  progress  of  the  malady  stayed,  by 
earl}^  and  free  incisions  carried  through  the  engorged  structures  (debri¬ 
dement)  ;  an  outlet  is  thus  afforded  to  the  effused  fluids  and  to  those 
portions  of  areolar  tissue  already  in  a  state  of  slough.  But  in  all 
others,  and  these  unfortunately  are  b}’’  far  the  most  numerous,  in  which 
the  true  traumatic  or  rapidly  spreading  gangrene  has  set  in,  the  Sur¬ 
geon  will  be  placed  in  a  great  difficulty,  whichever  way  he  act.  If  he 
trust  to  constitutional  treatment,  in  the  hope  of  a  line  of  demarcation 
forming,  he  will  almost  certainly  be  disappointed,  the  gangrene  rapidly 
spreading  up  to  the  trunk;  and  if  he  amputate,  he  ma}^  probablj^  lose 
his  patient  by  the  stump  becoming  affected.  Yet  amputation  should,  in 
my  opinion,  be  performed  at  once.  For,  although  this  operation  is 
necessarily  very  unfavorable  when  practised  in  these  cases,  in  conse¬ 
quence  of  the  gangrene  not  being  a  local  affection,  but  dependent  on 
constitutional  causes,  yet  it  must  be  remembered  that,  if  the  Surgeon 
wait  for  the  line  of  demarcation  or  trust  to  other  means,  such  as  inci¬ 
sions  or  general  treatment,  the  patient  will  almost  to  a  certaint3^  die. 
The  patient’s  safety  in  these  cases,  then,  lies  in  amputating  earl^^,  and 
removing  the  limb  high  above  the  part  affected  ;  thus,  in  spreading  gan¬ 
grene  of  the  arm,  at  the  shoulder-joint ;  and  of  the  leg,  in  the  upper 
part  of  the  thigh.  The  necessit}"  for  high  amputation  in  these  cases  is 
owing  to  the  gangrene  spreading  more  extensively  in  the  areolar  tissue 
than  it  does  in  the  skin  ;  and  hence  in  reality  invading  the  limb  to  a 
higher  point  than  it  appears  externally  to  do.  In  most  cases  it  will  be 
found  that  the  infiltration  precursory  to  the  gangrenous  mischief  runs 
up  one  side  of  the  limb — the  inner  or  posterior — to  a  much  greater 
extent  than  the  other.  In  amputating  under  such  circumstances,  the 
Surgeon  may  often  very  advantageous!}^  so  fashion  his  flaps  as  to 
exclude  as  much  as  possible  of  the  afl*ected  part  or  side  of  the  limb, 
forming  them  chiefly  from  that  least  affected.  A  principal  source  of 
danger  and  of  death,  after  amputation  in  these  cases,  is  the  great  dis¬ 
position  to  the  recurrence  of  the  morbid  condition  in  the  stump,  more 
particularly  in  the  lower  extremity.  Out  of  twelve  cases  in  which  I 
have  seen  or  done  amputation  for  this  disease,  this  recurrence  happened 
in  seven  instances.  This  tendenc}^  will  be  increased  by  the  proximity 
of  the  line  of  amputation  to  the  gangrenous  limit.  But,  even  under  the 
most  unfavorable  circumstances,  recovery  will  sometimes  take  place. 
Thus  I  have  seen  the  flaps  in  amputation  for  spreading  gangrene  infil¬ 
trated  with  gelatinous-looking  fluid,  and  3^et  recovery  take  place.  In  a 
man  whose  arm  I  amputated  at  the  shoulder-joint  for  spreading  gan¬ 
grene  of  the  limb,  the  infiltration  had  extended  as  high  as  the  scapula ; 
3’et  he  made  a  very  excellent  recoveiy.  In  the  lower  extremity*  the  lia¬ 
bility  to  recurrence  of  the  gangrene  is,  however,  very  much  greater ; 
and  there  can  be  but  very  little  prospect  of  saving  the  patient  if  the 
thigh  have  once  become  reddened  and  infiltrated,  even  though  the  gan¬ 
grene  do  not  extend  above  the  knee — invasion  of  the  stump  ensuing 
under  such  circumstances  with  almost  absolute  certainty*. 

Much  of  the  success  of  the  case  will  depend  on  the  after-treatment. 
This  must  consist  principally  of  light  dressings  to  the  stump,  full  doses 
of  liquor  opii,  and  the  early  and  free  administration  of  stimulants,  more 


PUNCTURED  WOUNDS. 


185 


particularly  brandy  and  wine;  and  attention  to  these  points  will  often 
bring  the  patient  through,  though  usually  not  without  much  difficulty 
and  great  constitutional  disturbance. 

The  question  as  to  the  period  at  which  amputation  should  be  per¬ 
formed  in  contused  wounds,  has  already  been  considered  at  pp.  56  to  58. 
It  may  be  generally  stated,  that  the  sooner  a  condemned  limb  is  taken  off, 
the  less  is  the  suffering,  and  the  better  the  chance  of  recovery  to  the 
patient ;  and  that,  consequenthq  primary  amputation  should  be  practised 
in  these  cases;  for,  notwithstanding  the  higher  rate  of  mortality  in  pri¬ 
mary  than  in  secondary  amputations,  it  is  absolutel}'’  necessary  in  many 
cases  to  remove  the  injured  limb  within  the  first  twenty-four  hours.  This 
higher  mortality  may  partly  be  dependent  on  the  accidents  that  require 
primary  amputation  being  more  severe  than  those  in  which  it  has  been 
thought  justifiable  to  attempt  to  save  the  limb  ;  and  certainly,  of  the  two 
alternatives  of  leaving  a  badl}^  crushed  and  mangled  limb  until  suppura¬ 
tion  has  set  up,  and  thus  exposing  the  patient  to  all  the  risks  of  gangrene, 
erysipelas,  pysemia,  etc.,  or  removing  it  at  once,  the  latter  is  the  one 
attended  with  least  danger  to  the  patient. 

A  limb  is  sometimes  so  severely  and  hopelessly  crushed  and  torn  that 
an}"  attempt  at  its  preservation  must  be  useless;  whilst  at  the  same  time 
the  patient  is  so  severely  injured  internally,  or  is  so  prostrated  by  the 
general  shock  to  the  system,  that  amputation  as  a  formal  operation 
would  be  as  useless  as  it  would  be  unjustifiable,  the  patient  having  at 
most,  perhaps,  but  a  few  hours  to  live.  In  these  circumstances  the  best 
thing  that  can  be  done  is  to  put  on  a  tourniquet  tightly  so  as  partly  to 
restrain  hemorrhage,  partly  by  the  pressure  of  the  band  to  restrain  the 
painful  quivering  of  the  muscles,  and  to  wrap  up  the  maimed  limb  in  a 
wet  cloth.  Should  it  have  been  nearly  completely  detached — merely 
hanging  on  by  shreds  of  the  lacerated  muscles — these  may  be  divided, 
and  thus  its  removal  effected  without  additional  shock  or  suffering  to 
the  patient. 

Brush- Burn. — There  is  a  peculiar  species  of  wound,  that  partakes 
perhaps  more  of  the  character  of  those  that  we  have  just  been  consider¬ 
ing  than  of  any  other  variety,  occasioned  by  rapid  and  severe  friction 
of  the  surface  of  the  body,  so  that  the  skin  becomes  abraded  and  the 
subjacent  tissues  somewhat  contused.  It  goes  by  the  name  of  a  “brush- 
burn,”  and  is  not  unfrequently  produced  in  the  manufacturing  districts, 
b}’^  the  surface  of  the  body  coming  into  contact  wuth  straps  or  portions 
of  machinery  in  rapid  revolution.  It  has  also  been  known  to  occur  in 
consequence  of  a  person  slipping  and  gliding  rapidly  down  a  long  and 
steep  Alpine  snow-slope.  In  this  injury  the  integumental  structures  are, 
as  it  were,  ground  off,  and  the  areolar  and  aponeurotic  structures  con¬ 
verted  into  an  eschar. 

The  Treatment  presents  nothing  special,  but  may  be  conducted  on  or¬ 
dinary  principles.  The  separation  of  the  eschars  must  be  facilitated  by 
w'ater-dressing  and  poultices;  the  resulting  sores  wdll  heal  by  granula¬ 
tion;  and  the  general  health  must  be  supported  during  the  suppurative 
period  that  must  necessarily  ensue. 

Punctured  Wounds,  made  by  narrow  sharp-pointed  instruments, 
vary  greatly  in  extent,  from  the  prick  of  a  needle  in  the  finger  to  a  sword- 
thrust  through  the  body.  Not  unfrequently  punctured  wounds  are 
somewhat  contused,  being  made  by  a  triangular  or  wedge-like  weapon, 
as  a  bayonet  or  lance-blade.  Hence  they  partake  of  the  general  character 
of  contused  wounds,  having  a  tendency  to  unite  by  granulation  from  the 
bottom,  and  to  be  accompanied  by  much  inflammatory  action.  When 


186 


INJURIES  OF  SOFT  PARTS. 


deep,  they  are  of  a  most  dangerous  character — wounding  bloodvessels, 
traversing  the  great  cavities,  and  injuring  the  contained  viscera. 

Treatment. — In  the  treatment  of  punctured  wounds,  the  principal 
points  are  to  arrest  the  hemorrhage,  and  to  facilitate  union. 

The  hemorrhage  must  be  arrested  b}'  pressure  properly  applied  by 
means  of  compresses  or  pads,  so  as  to  approximate  the  sides  of  the 
puncture;  b}"  the  application  of  cold;  or  by  cutting  down  on  the  injured 
vessel  if  it  be  a  large  one,  and  ligaturing  it  above  and  below  the  perfo¬ 
ration  in  it. 

In  the  majority  of  cases,  unless  the  injury  be  a  slight  one,  suppuration 
and  union  by  the  second  intention  will  take  place.  But  in  many  in¬ 
stances  union  bv  adhesion  is  obtained;  and  in  those  that  are  allowed  to 
suppurate,  there  can  be  little  doubt  that  the  same  favorable  termination 
might  be  secured  if  proper  attention  were  paid  to  the  injury.  The  cavit}’’ 
should  be  injected  with  carbolic  acid  lotion  ;  all  superfluous  moisture 
should  be  then  carefully  expressed;  the  external  opening  closed  by  collo¬ 
dion  or  stj'ptic  colloid,  or  after  Lister’s  method ;  and  the  sides  kept  in 
contact  by  compresses  and  bandages.  IJndue  inflammation  must  be  kept 
down  b}’’  cooling  lotions,  etc.  In  former  days,  when  duels  with  the  small 
sword  were  of  frequent  occurrence,  persons  called  “suckers,”  who  were 
often  the  drummers  of  a  regiment,  were  emplo3’ed  to  attend  the  wounded 
combatants.  Their  treatment,  which  was  conducted  with  a  certain  de¬ 
gree  of  mysteiy,  consisted  in  sucking  the  wound  till  all  blood  ceased  to 
flow,  and  then  appljung  a  pellet  of  chewed  paper  or  a  piece  of  wet  linen 
to  the  oriflce;  in  this  way  it  would  appear  that  many  sword-thrusts 
traversing  the  limbs  were  healed  in  a  few  hours  or  daj^s.  The  process 
of  suction  cleared  the  wound  thoroughl^’^  of  all  blood,  and,  drawing  the 
sides  into  close  apposition,  placed  the  parts  in  the  most  favorable  con¬ 
dition  possible  for  union  by  adhesion.  This  practice  might,  perhaps,  in 
many  cases  be  advantageously  imitated  in  the  present  da}’’  by  means  of 
a  cupping-glass  and  syringe. 

Amongst  the  varieties  of  punctured  wounds  that  are  most  commonly 
met  with  in  ordinary  practice,  are  those  which  are  occasioned  by  needles 
penetrating  into,  and  breaking  off  in  the  bod3^  These  accidents  chiefly 
occur  in  the  Angers  and  feet  and  about  the  nates ;  and,  though  trivial, 
are  often  extremely  troublesome,  both  to  Surgeon  and  patient.  When 
the  Surgeon  is  called  shortly  after  the  occurrence  of  the  accident,  he 
must  endeavor  to  remove  the  fragment  left  behind,  by  cutting  down  upon 
it.  In  doing  this  he  will  be  guided  by  the  situation  of  the  puncture,  and 
by  the  seat  of  pain,  and  sometimes  by  feeling  the  point  projecting  under 
the  skin.  In  man3"  cases  this  is  a  sufficiently  simple  proceeding;  in  others, 
however,  a  deep  and  troublesome  dissection  may  be  required,  especially 
when  the  fragment  of  needle  gets  into  or  under  the  sheaths  of  a  tendon.' 
I  have  had  occasion  to  undertake  somewhat  troublesome  dissections 
between  the  biceps  tendon  and  the  brachial  artery,  or  in  the  close  prox¬ 
imity  of  the  ulnar  artery,  for  the  removal  of  fragments  of  needles  lodged 
in  the  bend  of  the  arm  and  the  wrist.  For  the  purpose  of  extracting 
needles,  thorns,  splinters  of  wood,  and  other  foreign  bodies  of  small  size 
and  pointed  shape  lying  in  narrow  wounds,  the  forceps  shown  in  the  an¬ 
nexed  woodcut  (Fig.  69)  will  be  found  serviceable,  as  the3"  have  very 
fine  but  strong  and  well-serrated  points.  One  of  the  most  dangerous 
situations  for  a  needle  to  penetrate  is  into  the  anterior  part  of  the  knee- 
joint,  lodging  on  the  head  of  the  tibia  or  the  patella,  and  breaking  off 
short.  In  such  cases  the  broken  fragment  should  be  dissected  out  at 
once,  the  limb  put  on  a  splint,  and  the  ice-bag  applied,  so  as  to  restrain 


GUNSHOT  WOUNDS. 


187 


Fig.  69. 


I 


1,' 


.  inflammation  of  the  joint.  I  have  known  the  most  disastrous  and  dis¬ 
organizing  inflammation  and  suppuration  of  the  knee-joint  ensue,  with 
imminent  peril  to  life,  and  followed  by  ankylosis,  in 
consequence  of  a  portion  of  needle  having  been  allowed 
to  remain  imbedded  for  some  days  before  extraction. 

In  many  cases,  if  the  needle  have  been  lodged  for 
some  days,  the  Surgeon  will  fail  in  his  endeavors  to 
extract  it ;  and,  unless  the  indications  of  its  presence 
be  very  clear,  I  think  the  wiser  course  is  to  leave  it 
undisturbed,  and  to  trust  to  nature  for  its  elimination 
from  the  body,  as  it  will  seldom  be  found  when  sought 
for,  and,  indeed,  may  not  exist,  although  supposed  to 
be  present.  The  following  plan  of  ascertaining  whether 
a  portion  of  needle  be  really  impacted  has  been  sug¬ 
gested  by  Marshall.  A  powerful  magnet  is  to  be  held 
upon  the  part  for  a  quarter  of  an  hour,  so  as  to  influ¬ 
ence  the  fragment ;  a  finely  hung  polarized  needle  should 
then  be  suspended  over  it,  when,  if  any  iron  be  present, 
deflection  will  ensue. 

When  fish-hooks,  crochet-needles,  or  other  barbed  in¬ 
struments  have  been  run  into  the  flesh,  no  attempt  is 
to  be  made  to  withdraw  them  through  the  same  aper¬ 
ture  by  which  they  entered,  but  the  point  should  be 
pushed  in  so  as  to  emerge  through  the  skin,  the  shank 
then  divided  by  pliers,  and  the  barbed  end  drawn  out. 

The  Surgeon  is  often  called  upon  to  arrest  the  bleeding  from  the 
punctured  wound  inflicted  bj’’  the  leech.  Pressure  with  a  piece  of  fluffy 
lint  for  five  or  ten  minutes  usually  suffices,  or  the  bite  may  be  touched 
with  a  point  of  nitrate  of  silver;  but,  if  this  do  not  arrest  the  bleeding,  a 
needle  should  be  passed  across  the  bite,  and  a  silk  thread  wound  round 
it.  The  needle  can  be  removed  in  twenty-four  hours. 


f/' 


Forceps  for  remov¬ 
ing  Small  Pointed 
Bodies. 


CHAPTER  X. 

GUNSHOT  WOUNDS. 

Amongst  the  special  varieties  of  contused  and  lacerated  wounds,  none 
are  of  more  interest  than  the  different  forms  of  gunshot  injuiy.  Though 
comparativel3"  and  fortunatelj'  rare  in  civil  practice  in  this  country,  yet 
they  are  of  sufficient  frequent  occurrence  to  render  an  acquaintance  with 
them  indispensable  to  the  general  Surgeon.  To  the  military  Surgeon 
their  study  is  necessarily  one  of  peculiar  interest  and  importance  ;  and 
to  him  I  would  specially  recommend  the  perusal  of  the  works  of  Pare, 
W^iseman,  Hennen,  Guthrie,  Larrey,  and  Stromeyer,  and  of  other  Sur¬ 
geons  who  have  had  unusual  opportunities  of  studying  the  nature  of 
these  injuries  upon  the  field  of  battle,  and  by  whom  they  have  been 
treated  with  all  the  minuteness  of  a  speciality.  I  purpose  in  the  follow¬ 
ing  observations  chiefly  to  confine  myself  to  such  a  general  discussion 
of  the  subject  as  is  required  by  the  civil  Surgeon. 

Gunshot  injuries  constitute  a  species  of  contused  and  lacerated 
wounds,  characterized  in  some  cases  by  the  peculiar  appearance  pre- 


188 


GUNSHOT  WOUNDS. 


sentecl  by  the  color,  shape,  and  size  of  the  orifice ;  and  in  others  by  the 
extensive  injury  inflicted  on  parts,  both  superficial  and  deep-seated,  in 
consequence  of  which  the  wounds  may  prove  rapidly  or  immediately 
fatal.  If  the  sufferer  survive  the  immediate  effects  of  the  injury,  high 
inflammatory  action  with  much  pain  and  tension,  with  profuse  discharge, 
deep-seated  suppuration,  and  other  serious  and  veiy  protracted  after¬ 
consequences,  are  apt  to  set  in.  These  peculiarities  were  at  different 
times  attributed  to  the  parts  being  burnt  by  the  ball,  to  the  poisonous 
nature  of  projectiles,  and  to  electricity  developed  b}^  the  bullet  in  its 
passage  through  the  air,  or  b}^  the  fi  iction  against  the  barrel.  All  these 
opinions,  however,  have  been  shown  to  bo  erroneous ;  and  every  pecu¬ 
liarity  presented  by  these  injuries  can  be  accounted  for  b}^  the  bluntness 
of  the  contusing  bod}',  the  rapidity  of  its  course,  and  the  force  with 
which  it  is  driven.  As  John  Bell  has  pithily  stated,  “there  is  a  peculiarity, 
but  no  mysteiy,  in  giin-shot  wounds.”  That  the  sloughing  which  always 
occurs  in  the  track  of  a  bullet  wound  is  due  to  the  injury  being  inflicted 
by  a  blunt  body,  is  evident,  from  sharp  splinters  of  shell  having  been 
known  to  inflict  clean-cut  wounds. 

Characters. — Gunshot  wounds  vary  greatly  according  to  the  Na¬ 
ture  of  the  Projectile,  to  the  Force  with  which  it  is  driven,  and  to  the 
Direction  in  which  it  strikes. 

Nature  and  Force  of  Projectile. — Gunshot  injuries  of  a  serious  cha¬ 
racter  may  be  inflicted  by  iveapons  charged  only  ivith  powder.  They 
may  arise  from  the  mere  concussion  of  the  explosion;  thus  a  pistol 
charged  with  powder,  and  discharged  with  the  muzzle  resting  against 
the  chest  of  a  man,  has  been  known  to  kill  by  concussing  the  heart.  In 
other  cases  a  portion  of  the  unexploded  powder  may  be  driven  into  or 
through  the  skin  by  that  which  is  exploded  behind  it.  In  this  way,  very 
troublesome  and  disfiguring  marks  are  sometimes,  inflicted  on  the  face, 
and  other  parts  of  the  body,  b}'  the  charcoal  of  the  powder  being  driven 
into  the  skin.  That  a  weapon  so  charged  may  actually  kill  when  dis¬ 
charged  at  a  little  distance,  appears  from  a  case  related  by  Dupuytren, 
in  which  a  fowling-piece  charged  with  powder  onl}’’,  and  fired  at  the  dis¬ 
tance  of  two  or  three  feet  from  the  abdomen,  pierced  the  belly  with  a 
round  hole  and  killed  the  man.  The  mere  force  of  the  explosion  will 
sometimes  produce  serious  lacerations.  Suicides  occasionally  forget  to 
put  a  bullet  into  the  pistol,  and,  discharging  it  into  their  mouths,  blow 
open  the  cheeks,  and  injure  the  phaiynx  and  glottis  by  the  explosive 
force.  Some  3mars  ago  a  man -was.  brought  to  University  College  Hos¬ 
pital,  who  had  discharged  the  tube  of  an  Italian  iron.,  loaded  with  powder 
onl}',  into  his  mouth,  and  died  in  consequence  of  the  injuries  he  received. 
In  another  case,  in  the  same  Institution,  a  man  died  on  the  fifth  day  after 
firing  a  pistol  into  his  mouth,  of  asphyxia,  occasioned  b}'  sloughing  of  the 
pharynx  and  inflammation  of  the  glottis  and  larynx,  consequent  on  the 
scorch  of  the  explosion. 

Wadding  and  soft  materials.,  as  pieces  of  clothing,  will  occasionally 
inflict  serious  wounds  by  the  force  with  which  they  are  driven.  These 
injuries  often  happen  on  the  stage,  at  reviews,  fairs,  &c.  Taylor  relates 
several  instances  of  the  kind: — one  of  a  girl  killed  by  a  gun  charged 
with  paper  pellets ;  also,  one  of  a  man  who  was  killed  by  a  kid  glove 
fired  from  a  blunderbuss. 

Small  shot  often  inflict  serious  injuries,  and  these  are  most  commonly 
met  with  in  civil  practice.  If  the  person  wounded  be  within  a  few 
feet  of  the  muzzle  of  the  gun,  a  terribly  torn  and  lacerated  wound,  of 
a  very  serious  character,  even  worse  than  that  occasioned  by  a  bullet 


COUKSE  OF  A  BULLET. 


189 


will  be  inflicted  ;  for  the  shot,  not  being  scattered,  are  driven  through  the 
bod}’ in  a  comparatively  compact  mass,  tearing  the  tissues  to  a  great  extent. 

When  shots  scatter  as  they  fly,  they  produce  at  a  greater  distance  a 
less  serious  injury,  usually  lodging  in  the  subcutaneous  areolar  tissue, 
where  they  may  remain  for  years,  requiring  to  be  picked  out  with  a 
lancet ;  or  they  may  give  rise  to  suppuration.  Occasionally  shot,  by 
penetrating  an  important  part,  may  cause  serious  or  fatal  results ;  thus, 
a  single  shot  penetrating  the  eyeball  will  destroy  vision  ;  or,  lodging  in 
the  heart  or  in  the  femoral  vein,  may  give  rise  to  rapidly  fatal  results. 
A  patient  was  brought  to  University  College  Hospital,  who  had  flred  a 
pocket  pistol  loaded  with  small  shot  into  his  mouth  ;  after  death,  the 
shots  were  found  to  have  penetrated  the  anterior  portion  of  the  vertebral 
column,  in  which  they  were  deeply  lodged. 

Splinters  of  shells  inflict  grave  injury;  as  also  do  those  of  metal, 
wood,  or  stone,  carried  by  the  force  of  the  explosion,  as  in  blasting  and 
mining  operations.  These  latter  inflict  perhaps  the  worst  forms  of  in¬ 
jury  from  bodies  j^ropelled  by  explosive  force  that  are  met  with  in  civil 
practice.  In  siege  operations  much  injury  also  is  often  inflicted  by  the 
splinters  from  parapets,  or  the  forcible  throwing  up  of  gravel  and  small 
stones  by  the  explosion  of  shells.  In  naval  actions,  the  force  with  which 
splinters  of  wood  are  driven  when  struck  and  scattered  by  cannon-shot, 
is  so  great  as  to  inflict  the  most  serious  and  fatal  mischief.  A  particular 
form  of  injury  sometimes  met  with  in  civil  practice,  and  which  belongs  to 
this  class,  is  the  wound  of  the  eyeball  by  the  explosion  and  splintering  of 
faulty  percussion-caps.  Wounds  of  the  face  and  other  parts  from  the 
splashes  or  splinters  of  bullets  from  the  surface  of  targets,  are  of  common 
occurrence  among  markers  at  rifle-ranges. 

O  O 

Bullets^  slugs ^  and  grajje-shot  occasion  more  serious  wounds  than  any 
that  have  yet  been  described ;  lacerating  soft  parts,  fracturing  and 
crushing  bones,  tearing  asunder  vessels  and  nerves,  perforating  the  vis¬ 
cera,  and  occasionally  cutting  oflf  parts,  as  a  finger,  the  nose,  or  an  ear. 

The  general  introduction  of  rifled  fire-arms  into  modern  warfare  has 
greatly  increased  the  destructive  effects  produced  by  bullets.  The 
missile  is  now  comparatively  rarely  deflected  from  its 
course  by  the  resistance  offered  by  bones,  tendons,  or 
the  elastic  reaction  of  the  skin,  as  happened  with  the 
spherical  ball  ;  but  penetrates  in  a  straight  line  from 
the  point  struck,  tearing  through  the  soft  parts,  and 
splintering  the  bones  widely.  On  the  bones  especially, 
the  modern  conico-cylindrical  bullet  produces  the  most 
destructive  eff'ects ;  not  only  comminuting  the  part 
struck,  but  often  splitting  up  the  shaft  of  the  bone, 
by  its  wedge-like  action,  in  fissures  many  inches  long, 
leading  into  contiguous  joints.  (Fig.  70.)  In  conse¬ 
quence  of  this  greater  and  more  sudden  disorganiza¬ 
tion  of  the  soft  parts,  the  shock  to  the  nervous  system 
is  greater  when  a  person  is  struck  by  a  conico-cylin¬ 
drical  than  by  a  round  ball. 

Direction. — In  the  majority  of  cases,  a  bullet  tra¬ 
verses,  and  the  wound  has  two  apertures,  one  of 
entry,  the  other  of  exit ;  occasionally  it  happens, 
however,  that  in  consequence  of  the  ball  being  spent, 
or  of  the  piece  not  having  been  efficiently  loaded,  or 
of  the  oblique  direction  with  which  the  ball  strikes 
a  part,  it  merely  leaves  a  contusion  or  dent,  re- 


Fig.  70. 


Perforation  of  Right 
Femur  by  Bullet. 
Longitudinal  Splitting 
of  Bone.  (United  States 
Army  Museum.) 


190 


GUNSHOT  WOUNDS. 


bouiidiiig  or  glancing  off.  In  other  cases  there  is  only  one  aperture ; 
and  here  the  bullet,  partly  spent,  has  probably  lodged  in  the  soft  tis¬ 
sues,  in  a  bone,  or  in  a  cavit}^  of  a  hollow  organ,  as  the  bladder.  It 
sometimes  happens,  however,  that  the  ball  drops  out  through  the 
aperture  at  which  it  entered,  as  when  a  spent  ball  strikes  a  rib;  or  that 
it  carries  a  i^ouch  of  clothing  before  it,  which  enables  the  Surgeon 
to  withdraw  it.  One  bullet  may  even  make  more  than  two  apertures: 
thus  a  ball  has  been  known  to  split  against  the  sharp  edge  of  the  tibia, 
and  to  have  one  aperture  of  entry  and  two  of  exit ;  or  it  may  pass 
through  both  thighs  or  both  calves,  and  thus  occasion  four  apertures ; 
and  cases  have  been  recorded  in  which  five  wounds  even  have  been 
made  in  the  same  person  by  one  bullet.  Conico-c^dindrical  balls,  as 
has  been  already  observed,  tear  their  way  through  the  strongest  and 
densest  osseous  structures. 

The  direction  of  the  openings  is  often  of  importance  in  a  medico-legal 
as  well  as  in  a  surgical  point  of  view.  Thus,  Sir  Astley  Cooper,  by  at¬ 
tending  to  this  circumstance  in  a  case  of  murder,  ascertained  that  the 
fatal  shot  must  have  been  fired  by  a  left-handed  man ;  and  this  led  to 
the  detection  of  the  criminal.  These  apertures,  though  usually  opposite 
to  one  another  when  a  ball  traverses,  will  sometimes  take  a  very  remark¬ 
able  course,  the  bullet  being  deflected  by  meeting  with  obstacles  from 
bones,  or  by  the  elasticity  of  the  skin.  Thus  a  bullet  has  been  known 
to  strike  a  rib  and  to  be  deflected,  running  under  the  skin  to  the  opposite 
side  of  the  body  ;  so  again,  striking  one  temple,  it  has  been  carried  under 
the  scalp  to  the  other  side  of  the  head,  where  it  passed  out;  thus  ap¬ 
pearing  to  have  penetrated  important  cavities  which  in  reality  were  not 
wounded. 

The  Aijertures  of  Entry  and  of  Exit^  made  by  a  bullet,  deserve  at¬ 
tentive  consideration.  Much  discussion  has  arisen  as  to  whether  there 

be  any  difference  between 
these  apertures,  and,  if  so, 
to  what  it  is  owing.  That 
there  is  a  difference  in  the 
great  majorit}^  of  cases, 
there  can  be  no  doubt ; 
though  this  difference  is  as 
a  rule  not  so  decided  in 
the  case  of  the  modern 
rifle-ball  as  in  that  of  the 
spherical.  Thus,  in  the 
latter  instance,  the  hole 
made  by  the  entrance  of 
the  bullet  is  small,  circular 
in  shape,  less  than  the  dia¬ 
meter  of  the  ball  in  breadth, 
the  edges  slightly  inverted 
and  ecchymosed  (Fig.  71)  ; 
whereas,  in  the  former,  the 
aperture  of  entry  is  more 
lacerated  and  irregular  in 
outline,  often  linear,  crucial, 
or  starred,  and  larger  than  the  diameter  of  the  ball.  In  either  case  the 
hole  made  by  the  exit  of  the  ball  is  a  large,  somewhat  everted,  and  irre¬ 
gular  aperture,  into  which  two  or  three  fingers  may  be  freely  passed 
(Fig.  72).  In  some  cases,  however,  there  is  no  appreciable  difference 


Fig.  71. 


Gunshot  Wound.  Aperture  of  Entry. 


Fig.  72. 


INJURIES  FROM  CANNON-BALLS. 


191 


between  the  two ;  and  in  others,  after  a  time,  the  aperture  of  entry  is 
larger  than  that  of  exit. 

There  can  be  no  doubt  that  Guthrie  has  given  the  correct  explanation 
of  these  discrepancies,  when  he  states  tliat  the  amount  of  the  difference 
in  the  two  apertures  will  depend  partly  on  the  momentum  of  the  ball, 
and  partly  on  the  resistance  with  wdiich  it  meets.  If  the  ball  strike 
shortly  after  its  discharge,  at  the  maximum  of  its  velocity,  it  will  make 
but  a  small  round  hole,  not  so  much  shattering  the  parts  as  separating 
them.  If  it  traverse  a  part  composed  of  soft  tissue,  meeting  with  but 
little  resistance  in  its  passage,  it  loses  but  little  of  its  momentum  ; 
and  passing  out  of  the  body  with  nearl}^  the  same  force  as  that  with 
which  it  entered,  it  makes  an  aperture  of  exit  that  differs  but  slight!}',  if 
at  all,  from  that  of  entry.  If  the  ball  strike  a  bone  on  its  passage 
through  the  limb  or  body,  and  thus,  by  meeting  with  much  resistance, 
have  its  momentum  materially  lessened,  the  aperture  of  exit  will  be  torn, 
large,  and  ragged,  differing  materially  from  that  of  entry.  So  also,  we 
find  that  in  all  bullet-wounds  the  entrance-aperture  is  actually  less  in 
diameter  than  the  bullet  itself,  provided  it  be  made  whilst  the  ball 
is  moving  with  its  full  velocity ;  if  it  have  lost  much  of  its  momentum 
before  it  strikes,  then  the  entrance-wound  will  always  be  large  and 
ragged.  In  this  there  is  nothing  peculiar  to  the  tissues  of  the  living 
body  ;  the  same  happens  when  any  elastic  material,  as  a  piece  of  green 
timber,  is  struck.  Much,  however,  will  also  depend  on  the  period  at 
which  the  W'ound  is  examined.  In  the  early  stages,  for  the  reasons 
mentioned,  the  wound  of  entry  may  be  smaller  than  that  of  exit ; 
but,  as  the  eschar  which  forms  in  the  wound  of  entry  is  larger  than 
that  at  the  exit-aperture,  the  former  may,  in  a  later  stage,  appear 
larger  than  the  latter.  This  difference  in  the  size  of  the  two  wounds  I 
saw  well  exemplified  in  the  case  of  a  young  man  shot  through  the  neck 
in  a  duel  with  a  pistol-ball.  The  aperture  of  entry,  which  was  at  first 
the  smallest,  appeared  on  the  second  day  the  largest  in  consequence  of 
the  extrusion  of  a  black  eschar;  though  it  continued  more  regular  in 
shape  than  that  of  exit. 

Cannon-balls  inflict  two  kinds  of  injuries.  They  may  contuse  a  part 
deeply,  crushing  muscles  and  bones,  without  destroying  the  integrity  of 
the  skin,  the  ball  either  having  lost  its  velocity,  and  being  spent, 
or  striking  obliquely,  or  rolling  over  the  surface  of  the  body.  The 
elasticity  of  the  skin  preserves  this  from  injury,  though  all  the  sub¬ 
jacent  textures — bones,  muscles,  and  vessels — may  be  totally  disorgan¬ 
ized  and  crushed  into  a  pulp,  if  a  limb  be  struck;  if  the  trunk  itself  be 
injured,  the  vertebral  column  and  lumbar  muscles  may  be  disorganized, 
and  the  liver,  kidneys,  spleen,  stomach,  and  intestines  ruptured  without 
any  breach  of  surface.  These  injuries,  formerly  erroneously  attributed 
to  the  action  of  the  current  of  air  set  in  motion  by  the  ball,  go  by  the 
name  of  wind-contusions.  Subcutaneous  contusions  of  similar  character, 
though  less  severe  in  degree,  may  also  be  produced  by  bullets.  In  some 
of  these  contusions  gangrene  of  the  limb  sets  in  ;  apparently,  as  Guthrie 
has  pointed  out,  from  the  rupture  of  the  principal  vessels.  Cannon- 
shot  more  commonly  carry  away  the  whole  thickness  of  a  part,  tearing 
and  shattering  a  limb,  carrying  off  the  thick  and  fleshy  parts  of  thigh, 
calf,  or  shoulder;  or  they  may  inflict  the  most  fearful  injuries  by  smash¬ 
ing  the  trunk  and  head. 

Fragments  of  shelly  jjarticularly  if  large,  inflict  wounds  equally  de¬ 
structive  to  life  and  limb.  A  small  fragment  may  either  become  lodged, 


192 


GUNSHOT  WOUNDS. 


or  make  its  way  out,  the  aperture  of  entry  being  somewhat  incised, 
though  very  irregular,  and  the  aperture  of  exit  large  and  ragged. 

Symptoms. — The  chief  peculiarities  of  gunshot  injuries  consist  in 
the  amount  and  character  of  the  Pain,  the  severity  of  the  Shock,  the 
comparatively  little  liability  to  Hemorrhage,  and  the  severity  of  the 
Consecutive  Inflammation. 

The  Fain  in  gunshot  injuries  varies  greatl3^  It  is  most  severe  when 
a  bone  is  fractured,  or  a  large  cavity  penetrated ;  when  soft  structures 
alone  are  injured,  a  dull  and  heavy  sensation  is  experienced,  which  has 
often  been  compared  to  that  occasioned  by  a  blow  with  a  stick.  In 
many  cases  when  the  mind  is  actively  engaged,  as  in  the  height  of 
battle,  no  pain  is  experienced,  and  the  sufferer  does  not  know  that  he  is 
•wounded  until  he  is  told  so,  or  sees  the  blood.  Hennen  has  known  a 
limb  carried  off  or  smashed  to  pieces  by  a  cannon-shot,  without  the 
sufferer  being  conscious  of  it ;  and  Macleod  relates  the  case  of  an  officer 
who,  in  the  Crimea,  had  both  legs  carried  away,  and  who  was  not  aware 
of  the  injury  till  he  tried  to  rise. 

In  gunshot  injuries,  the  Shock  to  the  Nervous  System  is  always  very 
great  where  parts  of  importance,  as  the  head,  chest,  and  abdomen,  or 
large  joints,  as  the  knee,  are  opened  ;  and  the  severity  of  the  shock  is 
indicative  of  the  amount  of  mischief  inflicted.  As  has  alread}"  been 
stated,  the  shock  is  more  severe  when  a  wound  is  inflicted  by  a  conical 
bullet  from  a  rifle  than  when  made  by  a  splierical  ball  from  the  old 
smooth-bore.  Thus,  if  a  bullet  appear  to  have  traversed  the  chest,  but 
in  reality  has  been  deflected  under  the  skin,  the  comparative  absence  of 
shock  will  serve,  to  a  certain  extent,  to  prove  that  visceral  mischief  has 
not  been  inflicted.  In  some  cases  the  shock  alone  appears  sufficient  to 
kill ;  thus,  a  man  shot  b^'  a  pistol-bullet,  which  traversed  the  distended 
stomach,  died  in  a  few  seconds  from  shock,  there  being  no  bleeding  of 
importance,  or  other  discernible  cause  of  immediate  death  (Taylor). 
In  some  cases,  however,  that  are  mortal,  the  sj^mptoms  of  shock  are 
but  slight. 

The  Primary  Hemorrhage  from  gunshot  wounds  varies  necessarily 
according  to  the  situation  of  the  injury  and  the  size  of  the  vessels 
injured;  c set er is  paribus^  they  bleed  less  than  other  injuries  ;  but  in  all 
cases  a  certain  and  in  many  a  large  and  fatal  quantity  of  blood  is  lost. 
When  the  fleshy  parts  of  a  limb  are  perforated  b}-^  a  bullet,  the  hemor¬ 
rhage  is  usualty  very  trifling,  the  vessels  divided  being  small,  and  con¬ 
tused  rather  than  cut  across.  If  the  whole  of  a  limb  be  torn  away  by 
a  cannon-shot,  the  arteries  of  the  jagged  stump  left  do  not  bleed,  for 
the  same  reasons  that  those  of  a  limb  torn  away  by  machinery  do  not; 
viz.,  the  contraction  and  retraction  of  the  internal  and  middle  coats, 
and  the  twisting  of  the  external  cellular  coat  over  the  end  of  the  torn 
vessel.  This  explanation  is  disputed  b3"  Yerneuil,  who  has  described 
instances  where,  in  severe  gunshot  and  shell  wounds  of  the  leg  requiring 
amputation,  the  arteries  had  all  their  coats  cut  through  at  the  same 
level,  and  yet  liemorrhage  did  not  occur.  But,  though  it  may  be  stated 
as  a  general  rule  that  gunshot  wounds  do  not  bleed  much,  yet  when  a 
large  artery,  as  the  carotid,  iliac,  or  femoral,  is  cut  across,  violent  and 
suddenly  fatal  hemorrhage  will  occur — the  vessel  bleeding  as  freety  as 
if  divided  by^  the  knife.  Bullet-wounds  of  the  large  and  deep  arteries 
of  the  chest  and  abdomen  are  almost  immediately  fatal  from  hemor¬ 
rhage.  The  greater  number  of  those  who  die  in  the  field  of  battle  perish 
from  this  cause.  It  has  often  been  observed  that  arteries  escape,  though 
tying  apparently  in  the  direct  track  of  a  ball.  In  such  cases,  however. 


IMMEDIATE  TREATMENT. 


193 


though  primary'  hemorrhage  do  not  occur,  the  liability  to  secondary 
hemorrhage  is  great. 

Gunshot  wounds  alwa3"S  Inflame^  with  much  Sivelling^  Infiltration^ 
and  Tension.  The  pain,  which,  at  the  moment  of  infliction,  may  not 
have  been  severe,  becomes  extremely  acute  when  inflammation  has  set 
in,  owing  principally  to  the  great  tension.  This,  indeed,  is  one  of  the 
most  remarkable  phenomena  of  gunshot  injuiy,  and,  by  giving  rise  to 
straiio^ulation  of  the  tissues,  is  often  the  cause  of  serious  mischief.  The 
inflammation  speedily  terminates  in  suppuration,  often  most  profuse  and 
extensive,  not  only  in  the  track  of  the  ball,  but  widely  diffused  through 
the  neighboring  parts.  A  period  of  great  danger  in  gunshot  wounds  is 
that  about  which  the  sloughs  begin  to  separate,  usually  from  the  sixth 
to  the  twentieth  day;  and  up  to  this  time  it  is  often  impossible  to  know 
the  precise  extent  of  the  disorganization.  At  this  period,  also.  Con¬ 
secutive  Hemorrhage  is  vevy  apt  to  come  on,  after  veiy  slight  exertion, 
without  any  warning.  Baudens  states  that  this  occurrence  is  most 
likel3"  to  happen  on  the  sixth  day.  This  may  be  suddenl}’’  fatal,  and  is 
alwaj’s  more  dangerous  than  the  primaiy  hemorrhage,  not  only  on 
account  of  the  difficult}^  of  arresting  it,  but  likewise  from  the  patient 
being  already  weakened  by  inflammatory  and  suppurative  action. 
Secondaiy  hemorrhage  may  occur  from  other  causes  than  the  separa¬ 
tion  of  the  sloughs  and  the  consequent  opening  up  of  an  inflamed  artery. 
It  may  arise  from  wounds  of  an  arteiy  b}"  a  spiculum  of  fractured  bone; 
and  from  this  cause  it  may  arise  at  an^"  period  until  all  detached  bone 
is  separated  and  the  wound  firml}'-  cicatrized.  Chisholm,  of  the  Ameri¬ 
can  Confederate  arm}',  mentions  a  case  of  death  by  secondary  hemor¬ 
rhage  on  the  328th  day  after  a  gunshot  fracture  of  the  upper  third  of 
the  thigh,  owing  to  wound  of  the  femoral  artery  by  a  detached  seques¬ 
trum.  Independently  of  this  danger  from  secondary  hemorrhage,  the 
patient,  if  his  limb  be  saved,  may  have  to  undergo  long  and  tedious 
processes  of  exfoliation  of  dead  bone,  and  to  run  the  risk  of  intercur¬ 
rent  attacks  of  erysipelas,  hospital  gangrene,  and  visceral  mischief. 

There  is  every  reason  to  believe  that  warfare  in  modern  times  is  fully 
as  destructive  to  life  as  it  was  formerly,  if  not  much  more  so;  not  in  the 
proportion  of  the  killed  to  the  number  of  combatants  engaged,  but  in 
relation  to  the  recoveries  among  the  wounded.  This  at  first  appears 
remarkable,  when  we  consider  the  great  advances  that  have  of  late  years 
been  made  in  surgical  treatment  and  in  sanitary  arrangements.  But  it 
is  readily  explained  by  the  facts  that  the  size  and  form  of  the  projectiles 
used,  and  the  force  with  which  they  are  driven,  are  such  as  to  render  the 
wounds  inflicted  by  them  infinitely  more  destructive  than  they  used  to 
be ;  and  that  the  advance  in  surgical  treatment  is  thus  more  than  neu¬ 
tralized  by  the  more  deadly  nature  of  the  injuries  inflicted,  whilst  the 
enormous  number  of  men  engaged  has  yielded  so  great  an  amount  of 
sick  and  wounded  that,  after  the  first  few  weeks,  the  sanitary  arrange¬ 
ments  have  broken  down  under  the  pressure,  and  secondary  septic  dis¬ 
eases  have  committed  the  most  frightful  ravages.  The  surgical  statis¬ 
tics  of  the  great  Franco-German  war  have  not  yet  been  made  public; 
but,  so  far  as  can  be  ascertained,  there  can  be  but  little  doubt  that  the 
results  of  excisions  and  amputations,  as  well  as  those  attending  the 
treatment  of  compound  fractures,  have  been  far  less  satisfactory  than 
they  have  been  in  other  recent  wars. 

Treatment. — The  slighter  and  purely  superficial  gunshot  injuries 
generally  merely  require  to  be  treated  on  the  ordinary  principles  that 
guide  us  in  the  management  of  contusions  and  lacerations.  When  they 
VOL.  I. — 13 


194 


GUNSHOT  WOUNDS. 


affect  the  head,  chest,  or  abdomen,  they  present  so  many  circumstances 
of  special  importance,  that  we  must  defer  their  consideration  until  we 
treat  of  injuries  of  those  regions. 

In  all  cases  of  gunshot  wound,  whether  amputation  be  ultimately 
required  or  not,  certain  immediate  attentions  are  necessary  in  order  to 
place  the  sufferer  in  some  degree  of  comfort  and  safety.  Thus,  if  a  person 
be  shot  through  the  fleshy  part  of  a  limb,  no  bone  or  vessel  of  importance 
being  injured,  the  part  should  be  covered  with  wet  cloths,  and  placed  in 
an  easy  position.  If  tliere  be  abundant  venous  hemorrhage,  the  limb 
should  be  raised ;  and  if  this  do  not  arrest  the  bleeding,  a  compress 
should  be  used.  If  the  hemorrhage  be  arterial,  a  tourniquet  must  be 
applied.  So,  also,  a  tourniquet  should  be  applied  if  there  be  rapid  drip¬ 
ping  of  blood,  even  though  the  bleeding  be  not  in  a  jet. 

If  a  limb  be  smashed,  or  torn  away,  a  tourniquet  should  be  applied 
very  tightly  upon  the  stump,  which  must  be  covered  up  in  wet  cloths. 
The  pressure  of  the  tourniquet  will  not  only  arrest  hemorrhage,  but  will 
stay  that  spasmodic  quivering  of  the  muscles  of  the  mangled  limb  which 
is  so  painful  to  the  sufferer. 

If  the  head  or  neck  be  wounded,  cold  wet  pledgets  should  be  applied, 
and  hemorrhage,  whether  venous  or  arterial,  arrested  by  pressure  with 
the  fingers. 

If  the  chest  be  shot  through,  the  patient  should  be  laid  on  the  injured 
side,  and  cold  applied.  If  emphysema  occur,  or  if  air  freely  pass  through 
the  wound,  a  bodj'-bandage  must  be  tightly  applied. 

If  the  abdomen  be  wounded,  the  patient  should  be  laid  on  the  injured 
side,  if  the  aperture  be  lateral ;  if  it  be  central,  on  the  back,  with  the 
knees  bent  over  a  log  or  knapsack.  If  the  intestine  protrude,  it  must 
be  washed  and  quickly  returned. 

In  addition  to  those  immediate  attentions,  which  may  be  bestowed 
upon  sufferers  from  gunshot  wounds  before  they  are  sent  to  the  hospital 
for  more  methodical  treatment,  the  influence  of  the  shock  should  be 
counteracted  by  the  administration  of  a  little  brandy  and  water,  and 
plenty  of  cold  water  be  given  to  allay  thirst. 

Gunshot  Wounds  of  t/ie  Extremities  may  be  divided  into  two  great 
classes  in  reference  to  treatment :  I.  Those  that  do  not  require  ampu¬ 
tation.  II.  Those  in  which  amputation  is  necessary. 

I.  Those  cases  of  gunshot  injury  that  do  not  require  amputation  must 
be  treated  on  the  principles  that  guide  us  in  the  management  of  all  con¬ 
tused  and  lacerated  wounds;  the  Surgeon,  however,  bearing  in  mind  that 
these  injuries  are  especially  apt  to  be  followed  by  extensive  and  intense 
inflammatory  action,  and  that  sloughing  will  inevitably  result  in  every 
part  that  has  been  touched  by  the  ball. 

The  first  point  to  be  attended  to  in  these  cases  is  the  Arrest  of  Hemor¬ 
rhage.  In  general,  this  may  not  give  much  trouble;  but,  if  a  large  vessel 
be  injured,  the  loss  of  blood  will  rapidly  prove  fatal,  unless  immediately 
stopped.  This  is  done  in  the  first  instance  by  direct  pressure  with  the 
fingers  on  the  bleeding  part,  followed  by  the  application  of  the  tourni¬ 
quet ;  or,  if  this  instrument  be  not  at  hand,  of  some  simple  substitute, 
such  as  a  pebble,  of  about  the  size  of  an  egg,  rolled  in  the  middle  of  a  pocket- 
handkerchief  and  laid  over  the  artery,  the  ends  of  the  handkerchief  being 
knotted  round  the  limb,  and  then  twisted  up  tightly  with  a  piece  of  stick 
or  the  hilt  of  a  sword  passed  under  it  (Fig.  73).  The  wound  in  the  artery 
may  render  amputation  of  the  limb  necessary  ;  if  not,  hemorrhage  must 
be  permanently  arrested  by  making  an  incision  down  to  the  bleed- 


REMOV’AL  OF  BULLETS. 


195 


ing  vessel,  and  applying  a  ligature  on 
each  side  of  the  wound  in  it,  for  reasons 
that  will  be  fully  stated  when  we  come 
to  speak  of  Injuries  of  Arteries.  In 
military  practice  such  operations,  how¬ 
ever,  appear  to  be  very  rare,  and  the 
ligature  of  a  large  artery  for  primary 
hemorrhage  after  gunshot  injury  is 
scarcely  ever  practised.  The  fact  is 
that,  if  a  large  artery  be  wounded,  the 
patient  usually  dies  outright  from  he¬ 
morrhage  before  anything  can  be  done 
to  arrest  the  bleeding.  If  a  small  ves- 
sel  only  be  divided,  the  hemorrhage 
will  speedily  cease  of  itself. 

The  second  point  to  be  attended  to 
is  the  Extraction  of  Foreign  Bodies^ 
such  as  shot,  slugs,  or  bullets,  wad¬ 
ding,  pieces  of  clothing  that  have  been 
carried  in  with  the  ball,  splinters  of 
bone  and  other  matter  of  a  like  kind. 

These  will  generally  be  found  near  the 
aperture  of  exit,  through  which  they 
may  then  be  more  easily  extracted. 

If  the  bullet  lodge,  it,  together  with 
foreign  bodies  accompanying  it,  such 
as  pieces  of  clothing,  must  be  extracted  through  the  wound,  or  cut 
out  by  a  counter  opening.  This  second  opening  is  often  of  great  utility 
in  affording  a  ready  exit  for  discharge,  &c.  Palpation  of  the  limb  or 
region  struck  will  often  lead  to  the  discovery  of  the  bullet,  when  it  lies 
amongst  the  muscles  or  beneath  the  skin.  A  consideration  of  the  direc¬ 
tion  whence  the  bullet  came,  and  the  position  of  the  patient  when  hit,  will 
often  direct  attention  to  the  spot  where  it  has  lodged.  If  possible,  the 
same  position  of  body  or  limb  should  be  assumed;  the  track  of  the 
bullet  will  thus  be  straightened,  and  the  finger  or  probe  can  be  carried 
down  to  it  more  readily.  In  searching  for  bullets  and  other  foreign 
bodies,  care  should  be  taken  not  to  probe  the  wound  unnecessarily  from 
mere  curiosity,  or  so  as  to  excite  irritation;  in  many  cases,  the  introduc¬ 
tion  of  the  finger  is  far  more  useful  than  that  of  the  probe.  The  advice 
given  by  Ambroise  Pare,  three  hundred  years  ago,  with  regard  to  the 
examination  of  gunshot  wounds,  can  scarcely  be  improved  upon.  After 
advisinof  that  the  examination  of  the  wound  be  made  as  soon  after  the 
injury  as  possible,  before  swelling  and  inflammation  set  in,  he  says: 
“This  is  the  principal  thing  in  the  performance  of  this  work,  that  you 
place  the  patient  in  just  such  a  posture  as  he  was  in  at  the  receiving  of 
the  wound ;  for  otherwise  the  various  motions  and  turning  of  the  mus¬ 
cles  will  either  hinder  or  straighten  the  passage  forth  of  the  contained 
bodies.  You  shall,  if  it  be  possible,  search  for  these  bodies  with  your 
finger,  that  you  may  the  more  certainly  and  exactly  perceive  them.  Yet 
if  the  bullet  be  entered  somewhat  deep  in,  then  you  shall  search  for  it 
with  a  round  and  blunt  probe,  lest  you  put  the  patient  to  pain.”  The 
extraction  of  the  bullet  should  be  accomplished  without  delay,  before 
inflammation  has  set  in,  and  the  lips  and  sides  of  the  wound  have  become 
swollen.  As  Macleod  justly  observes,  the  extraction  of  the  ball  not 
only  removes  a  source  of  physical  irritation  and  suffering,  but  of  mental 


Fig.  73. 


Gunshot  Wound  of  Thigh:  Mode  of  Com¬ 
pressing  Artery  temporarily. 


196 


GUNSHOT  WOUNDS. 


disquietude.  The  mind  of  the  patient  becomes  more  tranquil  and  easy. 
Bullets  cannot  be  allowed  to  remain  lodged  in  the  body  with  impunity. 
It  is  true  that  in  some  cases  they  may  become  enc\^sted,  and  so  cease  to 
irritate;  but  in  the  great  majority  of  instances  they  produce  suffering 
and  constitutional  disturbance,  and  may  at  last  occasion  fatal  mischief; 
for,  although  a  bullet  may  continue  fixed  for  years,  yet  it  may  at  last, 
under  the  influence  of  muscular  action,  gravity,  or  the  absorption  of  fat, 
begin  to  move  and  to  give  rise  to  injurious  consequences.  If  anything 
be  very  tightly  fixed,  so  that  it  cannot  readily  be  removed,  it  must  be 
left  till  loosened  by  suppuration.  Sometimes  a  bullet  is  firmly  fixed  in 
the  cancellous  structure  of  the  articular  end  of  a  bone.  It  may  be  re¬ 
moved  thence  by  means  of  an  elevator  or  by  the  screw-probe. 

Various  instruments  are  used  for  the  detection  and  removal  of  bullets 
and  other  foreign  bodies.  There  is  usually  no  material  difficulty  in 
detecting  the  presence  of  a  bullet,  by  means  of  an  ordinary  steel  probe 
of  sufficient  length.  In  some  cases  of  peculiar  and  exceptional  difficulty, 


Fig.  74. 


Nfelaton’s 

Probe. 


Figs.  75,  76,  77. 


Fig.  78. 


Fig.  79. 


Bullet-screw,  Forceps,  and  Extractor.  Bullet-forceps. 


Hook  Splin¬ 
ter  Forceps. 


where  the  bullet  is  lodged  deeply  in  the  cancellous  structure  of  a  bone, 
or  amongst  swollen  and  infiltrated  tissues,  its  presence  may  be  detected 
by  the  ingenious  device  adopted  by  Nelaton  in  the  case  of  Garibaldi,  of 


TREATMENT  OF  INFLAMMATION. 


197 


passing  a  probe  armed  with  a  piece  of  unglazed  porcelain  down  to  the 
suspected  site  of  the  bullet,  and  seeing  if  a  streak  of  lead  was  left  on  the 
rougli  surface  of  the  china  (Fig.  74).  Bullet-detectors  have  also  been 
contrived,  in  which,  by  an  arrangement  of  two  isolated  metal  probes  in 
a  cannula  connected  wdth  a  galvanometer,  the  galvanic  circuit  is  con- 
pleted  when  the  bullet  is  touched,  and  the  needle  of  the  galvanometer 
deflected;  or,  instead  of  the  latter  instrument,  the  ordinary  telegraph 
alarum  may  be  interposed.  For  the  removal  of  bullets,  long  and  strong 
forceps  are  required,  the  action  of  which  may  be  aided  by  a  screw  probe. 
The  accompanying  woodcuts  (Figs.  75,  76,  77,  and  78)  represent  the  best 
forms  of  bullet-screws,  forceps,  and  extractors. 

The  splinters  produced  by  the  passage  of  a  ball  through  a  bone  are 
more  numerous  and  larger,  when  the  injury  has  been  inflicted  with  a 
conical  rifle-ball.  The  impetus  of  this  projectile  is  so  great,  and  its 
wedge-like  action  so  destructive,  that  the  bone  struck  is  shattered  into 
a  great  multitude  of  fragments,  as  well  as  split  longitudinally  often  to  a 
great  extent.  These  fragments  are  detached  to  a  greater  or  less  extent 
from  their  connections  wdth  the  soft  parts,  and  carried  out  of  the  axis  of 
the  limb.  Dupuytren,  who  was  fond  of  systematizing,  has  classifled 
splinters  of  this  kind  under  the  three  heads  of  primary^  secondary^  and 
tertiary.  By  primary  splinters  are  meant  those  which  are  carried  com- 
pletel3’’  across  the  limb,  detached  from  the  soft  parts,  and  lodged  near 
the  aperture  of  exit.  The  secondary  splinters  are  those  which  are  still 
adherent  by  an  edge  to  a  strip  of  periosteum  or  to  the  fibrous  tissue;  and 
the  tertiary  are  those  portions  of  bone  wdiich,  from  the  violence  done  to 
them,  often  necrose  and  separate  at  a  subsequent  period.  The  treatment 
of  these  different  splinters  must  necessarily  vaiy.  The  primaiy,  which 
are  alread}"  completely'  detached  and  are  insusceptible  of  consolidation, 
must  be  treated  as  foreign  bodies  and  extracted.  The  secondary,  if  veiy 
loose,  must  also  be  removed ;  but,  if  more  firmly'  fixed,  they'  may  be  pushed 
into  the  axis  of  the  injured  bone  and  left,  when  they  may  become  con¬ 
solidated  by^  callus,  and  so  serve  in  the  reconstruction  of  the  bone.  The 
tertiary,  which  do  not  separate  until  about  six  or  seven  weeks,  must  be 
removed  as  soon  as  possible;  if  they'  become  engaged  in  a  mass  of  callus, 
it  may  be  a  considerable  time  before  they  are  loose  enough  to  be  re¬ 
moved  ;  and,  until  then,  sinuses  leading  down  to  them  will  remain  open 
even  for  vears. 

The  reunion  of  comminuted  gunshot  fractures  may'  be  assisted  by'’  the 
resection  of  the  fractured  ends  of  the  bones,  in  appropriate  cases.  This 
plan  has  been  especially'  successful  in  the  bones  of  the  upper  extremi¬ 
ties.  The  ends  thus  resected  may  furthermore  be  kept  in  apposition 
by  metallic  sutures,  according  to  the  plan  suggested  by'  How'ard  of  the 
American  army. 

In  those  cases  in  which  small  shot  are  lodged  under  the  skin,  they 
may  be  turned  out  by'  being  cut  down  w'ith  a  fine  scalpel. 

The  Treatment  of  the  Wound  itself  must  be  conducted  on  ordinary' 
surgical  principles.  As  has  already'  been  stated,  there  will,  as  a  rule,  be 
violent  inflammation  and  sloughing  along  the  whole  track  of  the  ball ; 
although  instances  have  been  recorded  of  primary'  union  in  gunshot 
wounds  uncomplicated  with  fracture  or  the  lodgment  of  foreign  bodies. 
The  principal  points  to  be  attended  to  are,  consequently',  to  limit  the 
inflammation,  to  watch  and  facilitate  the  separation  of  the  sloughs,  and 
to  pay  scrupulous  attention  to  cleanliness. 

By'  adopting  in  suitable  cases,  and  in  circumstances  where  the  requi¬ 
site  time  and  attention  can  be  spared,  the  antiseptic  method,  both 


198 


GUNSHOT  WOUNDS. 


inflammatory  action  and  the  separation  of  sloughs  may  be  avoided. 
Under  this  treatment,  repair  of  gunshot  fracture  without  suppuration 
or  sloughing  has  in  at  least  one  instance  been  reported.  In  any  case, 
no  harm  can  accrue  if  the  first  dressing  be  conducted  after  that  plan ; 
if  suppuration  then  ensue,  it  ma}'-  still  be  treated  by  the  usual  methods 
without  detriment  to  the  patient,  who  will  have  had  the  chance  given 
him  of  escaping  the  suflferings  and  exhaustion  attendant  on  the  healing 
of  an  extensive  wound  by  the  second  intention. 

In  order  to  limit  the  inflammation,  it  was  a  common  practice  with 
militaiy  Surgeons,  and  still  is  so  with  the  French,  to  dilate  by  incision 
the  w’ound  made  by  the  ball,  with  a  view  of  preventing  tension  and 
strangulation  of  parts.  Since  the  time,  however,  when  John  Hunter 
pointed  out  that  an  incision  could  not  alter  the  nature  of  a  contused 
wound,  and  onl}’  superadded  another  injur}'  to  the  one  already  infiicted 
by  the  bullet,  British  Surgeons  have  employed  the  knife,  in  the  early 
stages  of  gunshot  wounds,  only  for  the  purpose  of  facilitating  the 
securing  of  bleeding  vessels  or  the  extraction  of  foreign  bodies.  In 
the  more  advanced  stages,  however,  free  incisions,  wdiich  should  be  made 
in  the  direction  of  the  axis  of  the  limb,  are  commonly  required  in  order 
to  lessen  inflammatory  tension,  to  jjrevent  the  extension  of  sloughing, 
and  to  favor  the  escape  of  matter. 

The  best  mode  of  lesseninor  inflammation  in  a  o-unshot  wound  in  the 
early  stages,  and  more  especially  in  hot  climates,  is  either  by  cold  irri¬ 
gation  or  by  the  application  of  dry  cold  by  means  of  ice  in  India-rubber 
bags,  conjoined  with  position  and  rest ;  at  a  later  period,  water-dressing 
and  poultices  will  be  more  useful.  As  suppuration  comes  on,  we  must 
substitute  warm  applications  for  the  cold,  so  as  to  hasten  the  formation 
of  matter  and  the  separation  of  the  sloughs,  w’hilst  disinfectants  should 
be  freely  used  to  the  w'hole  cavity  of  the  wound.  All  bagging  and  bur¬ 
rowing  of  matter  must  be  carefully  guarded  against  by  position  and 
pressure,  or,  if  need  be,  by  a  counter-opening.  Free  incisions  may  also 
now'  be  required.  These  should  not  be  delayed  too  long.  They  may  be 
required  for  two  purposes ;  first,  to  remove  the  tension  resulting  from 
deep  infiltration  of  the  limb  by  infiammatory  effusions,  and  thus  to  pre¬ 
vent  the  strangulation  of  the  tissues,  and  to  remove  the  severe  consti¬ 
tutional  reaction  that  is  always  consequent  to  and  dependent  upon  this 
local  infiammatory  tension  ;  and  secondly,  with  the  view  of  opening  up 
purulent  collections,  w  hich  often  depend  upon  the  irritation  of  splinters, 
portions  of  clothing,  and  other  foreign  bodies  that  could  not  be  removed 
in  the  first  instance.  When  the  inflammatory  action  runs  very  high  and 
will  not  yield  to  the  measures  just  enumerated,  it  may  be  necessary  to 
•compress  or  tie  the  main  artery  leading  to  the  part.  At  the  period  of 
the  loosening  and  separation  of  the  sloughs,  there  is  always  especial 
danger  of  the  supervention  of  consecutive  hemorrhage.  The  patient, 
consequently,  at  this  time  requires  to  be  carefully  watched  :  if  the  wound 
be  in  the  vicinity  of  large  vessels,  he  should  have  a  tourniquet  placed 
loosely  round  the  limb,  so  as  to  be  screwed  up  at  a  moment’s  notice  ; 
and  he  must,  on  the  supervention  of  bleeding,  have  the  artery  ligatured, 
if  possible,  at  the  seat  of  the  w^ound ;  if  this  be  not  practicable,  in  the 
most  convenient  situation  above  it ;  and  if  this  do  not  arrest  the  bleed¬ 
ing,  recourse  should  be  had  to  amputation.  In  secondary  hemorrhage 
following  gunshot  wounds,  Xeudorfer  recommends  the  employment  of  a 
temporary  ligature.  The  method  adopted  by  him  consists  in  exposing 
the  artery  exactly  as  in  the  ordinary  operation  for  the  ligature  ;  a  silk 
thread  or  a  wire  is  then  passed  round  the  vessel,  and  the  tw'o  ends  are 


CONDITIONS  REQUIRING  AMPUTATION. 


199 


carried  through  the  soft  parts  on  one  side  of  the  wound,  so  that  they 
appear,  one  about  half  an  inch  from  the  edge,  the  other  about  half  or 
three-quarters  of  an  inch  from  the  first.  They  are  then  fastened  to  a  half 
cylinder  of  cork,  and  are  left  from  forty-eight  to  seventy-two  hours, 
when  they  are  removed. 

Serious  after-consequences,  such  as  abscesses,  profuse  discharges, 
necrosis,  osteomyelitis,  and  the  separation  of  splinters  of  bone,  must  be 
looked  for  in  many  cases ;  and  these  consequences  may  be  prolonged  for 
many  years,  at  last  perhaps  wearing  out  the  patient  if  the  cause  of  irri¬ 
tation  be  not  removed.  Thus  General  Bern  required  to  have  a  bullet 
removed  by  Liston  from  the  external  condyle  of  his  femur,  nineteen 
years  after  it  first  lodged  there ;  and  Marshal  Moncey  died  forty  3!^ears 
after  the  receipt  of  a  gunshot  wound,  from  its  eflects.  A  soldier  who 
was  wounded  at  the  storming  of  the  Redan,  died  under  my  care  in  the 
University  College  Hospital,  two  years  and  a  half  after  this  event,  of 
exhaustion  resulting  from  a  large  lumbar  abscess.  On  examination  it 
was  found  that  the  bullet,  which  had  entered  the  left  side  of  the  chest 
and  wounded  the  lung,  traversed  the  diaphragm,  notched  the  spleen, 
passed  between  the  kidney  and  suprarenal  body,  and  perforated  the 
spine,  was  tying  encapsuled  on  the  right  side  of  one  of  the  vertebrae, 
pressing  upon  the  right  renal  vessels.  Its  irritation,  and  that  of  the 
sequestra  from  the  injured  spine,  produced  the  abscess,  from  the  effect 
of  which  the  patient  died. 

The  aperture  of  exit  always  heals  sooner  than  the  aperture  of  entry ; 
owing,  probabty’,  as  Neudbrfer  observes,  to  the  bullet  having  lost  its 
lateral  action  in  its  passage  through  the  tissues,  and  merely  cutting  its 
waj'^  out.  It  is  at  the  point,  he  remarks,  where  the  lateral  action  is  lost, 
that  healing  begins. 

II.  Amputation  is  required  in  gunshot  injuries  in  two  classes  of  cases 
of  very  dissimilar  character. 

In  cases  where  the  limb  has  been  wholly  or  in  part  carried  away,  where 
it  is  evidently  hopelessly  shattered,  the  ragged,  conical,  and  quivering 
stump,  or  the  mangled  remains  of  the  limb,  must  be  removed.  In  such 
cases  there  can  be  no  doubt  whatever  in  the  mind  of  au^^  Surgeon,  as  to 
the  necessity  for  immediate  amputation. 

But  there  is  another  class  of  cases,  where  amputation  is  also  very 
commonl}^-  required,  though,  to  a  Surgeon  judging  from  the  accidents  of 
civil  life,  it  might  not  at  first  appear  necessaiy.  These  are,  especially, 
cases  of  compound  gunshot  fractures  of  the  thigh,  bullet  wounds  of  the 
knee-joint,  and  man3"  similar  injuries  of  the  leg.  Similar  injuries,  occur¬ 
ring  from  other  causes  in  civil  practice,  might  admit  of  an  attempt  being 
made  to  save  the  limb.  But  in  military  practice  it  is  different :  here 
the  attempt  to  save  the  limb  maybe  followed  b^"  such  extreme  local  and 
constitutional  disturbance  as  to  jeopardize  serioustyq  and  probably  to 
destroy,  the  patient’s  life.  In  such  circumstances,  conservatism  is  often 
a  fatal  error,  and  to  save  life  the  limb  must  be  sacrificed.  The  injury 
for  which  an  experienced  army  Surgeon  kno’ws  that  amputation  is 
imperative,  may  look  but  trifling,  and  to  the  patient  himself,  or  to  the 
civilian,  ma}^  appear  to  admit  of  treatment  by  less  severe  procedure ; 
but  experience  has  incontestably  shown  that  amputation  is  almost  the 
only  hope  of  safety  in  gunshot  wounds  of  the  lower  third  of  the  thigh 
and  of  the  leg,  fracturing  the  bones,  or  injuring  the  knee-joint.  Dupu^'- 
tren  states  that,  in  rejecting  amputation  in  compound  fractures  of  the 
extremities  from  gunshot,  we  lose  more  lives  than  we  save  limbs;  and 
Hennen  is  of  opinion  that  all  ‘‘ambiguous  cases”  should  be  amputated. 


200 


GUNSHOT  WOUNDS. 


The  following  is  a  specification  of  the  chief  conditions  in  which  am¬ 
putation  is  required. 

1.  When  the  whole  limb  is  carried  off,  a  ragged  stump  merely  being 
left ;  so,  likewise,  if  the  limb  be  completely  crushed  and  disorganized, 
whether  b}^  direct  blow  or  by  a  “  wind-contusion,”  though  still  left  adhe¬ 
rent  ;  or  again,  if  the  principal  vessels  and  soft  parts  be  carried  away, 
though  the  bone  be  uninjured,  the  limb  cannot  be  preserved. 

2.  Amputation  is  especially  necessary  in  some  of  the  more  serious 
injuries  of  the  lower  extremity  ;  thus,  if  a  bullet  divide  the  femoral 
vessels  or  the  sciatic  nerve,  and  splinter  the  thigh-bone  ;  or  if  the  sciatic 
nerve  and  soft  parts  at  the  back  of  the  thigh  be  carried  away,  although 
the  vessels  and  bone  be  left  uninjured,  the  case  is  one  for  amputation; 
and,  indeed,  it  may  be  stated  generally  (though,  doubtless,  there  are 
exceptions  to  this,  as  to  all  general  rules  in  surgery)  that  all  compound 
fractures  of  the  lower  third  of  the  femur  occasioned  by  gunshot  require 
amputation.  The  mortality,  however,  after  amputation  for  gunshot 
injury  of  the  upper  two-thirds  of  the  thigh  is  so  very  great,  that  many 
Surgeons  have  abandoned  the  operation  in  these  cases,  and  professional 
opinion  is  unsettled  as  to  the  course  that  should  be  pursued.  In  the 
Schleswig-Holstein  war  of  1849,  it  became  a  question  with  many  of  the 
German  and  Danish  Surgeons  'whether  this  operation  should  be  continued, 
or  whether  the  patient  would  not  have  a  better  chance  if  the  injury  were 
treated  on  ordinary  principles  as  a  compound  fracture.  At  the  siege  of 
Sebastopol,  the  mortality  after  amputation  of  the  upper  third  of  the 
thigh  was  so  great  in  the  Russian  army,  that  the  Surgeons  abandoned 
the  operation.  On  the  other  hand,  it  is  stated  in  the  Report  of  the  Black 
Sea  Fleet,  that  to  attempt  to  save  the  limb  in  any  case  of  gunshot  fracture 
of  the  thigh  was  to  endanger  the  patient’s  life.  In  the  Crimea,  Macleod 
states,  a  bad  compound  fracture  of  the  thigh  from  gunshot  was  syno¬ 
nymous  with  death.  This  was  partly  owing  to  the  bad  health  of  the 
troops,  and  partly  to  the  terrible  effects  of  conical  balls.  In  India, 
where  round  bullets  and  matchlock  balls  are  more  used,  the  result  is  not 
so  bad. 

Macleod  states  that,  although  he  made  every  inquiry,  he  could  hear  of 
three  cases  only  in  which  recovery  had,  in  the  Crimea,  follow^ed  a  com¬ 
pound  fracture  of  the  upper  third  of  the  thigh-bone  without  amputation. 
But,  exceptional  as  were  such  recoveries,  he  states  that  they  were  not  so 
rare  as  after  amputation  for  similar  injuries;  as  indeed  was  proved  by 
the  fact  of  not  one  patient  recovering  after  amputation  at  the  hip-joint. 
Hutin,  the  Surgeon  to  the  Invalides  in  Paris,  was  able  to  discover 
twentj^-four  cases  of  recovery  after  compound  fracture  above  the  middle 
of  the  thigh,  but  no  case  of  recovery  after  amputation  for  injuiy  of  the 
same  part.  In  the  British  army  in  the  Crimea,  the  amputations  in  the 
upper  third  of  the  thigh,  which  must  have  been  for  compound  fractures 
low  down  in  the  bone,  were  fatal,  in  the  ratio  of  86  per  cent. ;  of  those 
in  the  middle,  probably  for  injuries  of  the  low'er  articular  end  and  knee, 
60  per  cent,  died ;  whilst  of  those  in  the  low  er  third,  which  must  have 
been  for  injuries  of  the  knee  and  leg,  the  mortality  w’as  reduced  to  56 
per  cent.  The  conclusions  at  which  Macleod  arrives  after  a  careful 
inquiry  into  this  point,  are  so  important,  that  I  give  them  in  his  own 
words.  He  says,  “Under  circumstances  of  war  similar  to  those  which 
occurred  in  the  East,  we  ought  to  try  to  save  compound  comminuted 
fractures  of  the  thigh  wiien  situated  in  the  upper  third;  but  immediate 
amputation  should  be  had  recourse  to  in  the  case  of  a  like  accident 
occurring  in  the  middle  and  lower  thirds.”  In  the  great  civil  war  in 


WOUNDS  OF  THE  FOOT  AND  JOINTS. 


201 


America,  the  opinions  of  Surgeons  appear  to  have  been  divided  on  this 
point ;  and  the  conclusion  arrived  at  seems  to  have  been  that,  provided 
the  large  vessels  and  nerves  were  not  injured,  and  the  circumstances  in 
which  the  patient  was  placed  as  to  conveyance  not  too  unfavorable,  the 
chance  of  recovery  would  be  equal  whether  amputation  were  performed 
or  an  attempt  made,  aided  by  the  free  use  of  antiseptics,  to  save  the 
limb.  But  even  in  these  circumstances  Hamilton  states  that,  although 
his  experience  in  that  great  war  has  led  him  to  the  conclusion  that  in  the 
upper  third  the  life  is  least  hazarded  by  an  attempt  to  save  the  limb,  in 
the  middle  third  conservatism  and  amputation  afford  an  equal  chance, 
whilst  in  the  lower  third  of  the  thigh  the  chances  are  in  favor  of  ampu¬ 
tation.  This  is  a  conclusion  very  similar  to  that  arrived  at  by  British 
Surgeons.  When  an  attempt  is  made  to  save  the  limb,  an  apparatus, 
the  distinctive  principle  of  which  is  continuous  extension  and  counter¬ 
extension,  with  but  few  splints  and  bandages,  should  be  used ;  so  the 
limb  may  be  securely  fixed  in  the  plaster-of-Paris  apparatus. 

3.  In  gunshot  fractures  of  the  hones  of  the  leg^  amputation  becomes 
necessary  if  the  tibial  arteries  be  injured,  or  if  the  knee  or  ankle-joint 
be  badly  wounded.  If  the  injury  be  in  the  middle  of  the  leg,  at  a  dis¬ 
tance  from  these  joints,  and  provided  there  be  not  longitudinal  fissuring 
of  the  bone  leading  into  them,  much  may  be  done  to  save  the  limb,  by 
the  extraction  of  splinters,  and  the  removal  of  sharp  and  angular  frag¬ 
ments  of  bone,  the  limb  being  put  up  in  the  plaster-of-Paris  apparatus. 
In  such  cases,  the  patient  may  recover  with  a  shortened  but  otherwise 
useful  limb. 

4.  Gunshot  wounds  of  the  foot^  if  perforating  and  splintering  the 
tarsus,  require  its  removal,  either  at  or  above  the  ankle.  Those  of  the 
hand  are  of  special  interest  from  their  frequency,  in  consequence  of  the 
bursting  of  guns,  or  of  powder-flask  explosions.  In  these  cases,  however 
extensive  the  injuiy  may  be  that  is  inflicted  upon  the  hand,  fingers  being 
blown  away,  the  thumb  thrown  back,  and  the  metacarpal  bones  splin¬ 
tered,  we  must  endeavor,  if  possible,  to  save  a  portion  of  it,  if  it  be  only 
one  or  two  fingers  ;  and,  owing  to  the  great  reparative  power  possessed 
by  the  hand,  we  shall  often,  in  the  worst-looking  cases,  be  able  to  accom¬ 
plish  this.  If  the  thumb,  with  one  finger  as  an  opponent,  can  be  pre¬ 
served,  it  will  be  of  more  service  to  the  patient  than  any  artificial  con¬ 
trivance,  however  ingeniously  made.  It  not  unfrequently  happens  that 
amputation  may  be  required  in  the  more  advanced  stages  of  gunshot 
injury,  in  consequence  of  mortification.  In  these  circumstances,  it  must 
be  practised  without  delay,  and  without  w^aiting  for  the  line  of  separation. 
If,  in  consequence  of  long-continued  suffering  and  discharge,  the  patient’s 
health  becomes  worn  out,  and  the  limb  remain  an  useless  appendage, 
amputation  will  at  last  be  imperative. 

5.  Gunshot  injuries  of  joints  are  necessarily  most  serious  and  fatal — 
the  danger  depending  on  the  size  and  complexity  of  the  articulation, 
rather  than  on  the  extent  of  the  injury.  Wounds  of  any  of  the  three 
large  joints  of  the  lower  extremity  are  especially  dangerous  and  fatal ; 
those  of  the  upper  extremity  are  more  readily,  and  indeed  commonly, 
recovered  from.  The  fact  of  a  joint  being  wounded  is  commonly  obvious 
enough  from  the  direction  taken  by  the  bail,  the  comminution  of  the 
bones,  and  perhaps  the  escape  of  synovia;  but  a  joint  may  be  fatally 
injured  by  the  longitudinal  splitting  of  the  bone  into  it,  although  the 
bullet  has  not  passed  within  some  inches  of  it. 

In  bullet-wounds  of  joints,  excision  may  be  advantageously  substituted 
for  amputation  in  cases  where  the  soft  parts  are  not  too  extensively 


202 


GUNSHOT  WOUNDS. 


torn,  the  large  nerves  and  vessels  are  uninjured,  and  the  shaft  of  the 
bone  not  too  widely  splintered,  the  mischief  being  chiefly  confined  to  the 
articular  ends. 

Bullet-wounds  of  the  head^  neck^  or  trochanters  of  the  femur  ^  splintering 
the  bone  into  the  articulation,  are  necessarily''  most  serious.  If  they  be 
left  to  palliative  treatment,  the  death  of  the  patient  may  be  considered 
as  almost  inevitable  ;  if  amputation  at  the  hip  be  performed,  the  prospect 
is  better ;  and,  though  desperate,  the  case  must  not  be  considered  as 
hopeless.  This  is  well  illustrated  by  the  result  of  amputations  in  the 
great  war  of  the  American  rebellion  (p.  92).  In  Primary  amputations 
at  the  hip-joint  for  gunshot  injury,  the  mortality  was,  according  to  one 
estimate,  94,  according  to  another,  and  I  think  more  correct,  84  per  cent. 
All  Intermediate  amputations  were  fatal,  the  Secondary  ones  only  at 
the  rate  of  77  per  cent.  If  the  shaft  be  not  too  much  implicated,  it  is 
probable  that  the  best  hope  lies  in  the  excision  of  the  splintered  bone,  and 
the  careful  removal  of  the  loose  fragments.  This  operation,  originally 
proposed  by''  Guthrie,  and  first  successfully  performed  by  O’Leary  in  the 
Crimean  w'ar,  presents  the  most  reasonable,  though  but  a  slender,  hope 
of  safety'^  to  the  patient,  and  should  accordingly^  be  practised.  With  this 
view  the  wound  must  be  laid  freely  open,  loose  fragments  extracted,  and 
the  upper  end  of  the  bone  detached,  turned  out,  and  sawn  off.  Of  six 
cases  in  which  this  was  done  in  the  Crimea,  one  patient,  O’Leary’s, 
recovered. 

Bullet-wounds  of  the  knee-joint  are  amongst  the  most  serious  injuries 
in  surgery;  and  this  whether  the  bones  be  much  comminuted  or  not, 
provided  the  epiphy^sis  of  the  tibia  or  femur  be  perforated,  or  the  articu¬ 
lation  be  fairly’^  traversed  or  even  penetrated  by  the  ball.  Prior  to  the 
American  war  there  were  but  seven  cases  in  which  excision  of  the  knee 
had  been  done  for  gunshot  injury — five  in  military,  two  in  civil  practice  ; 
the  two  latter  cases  recovered,  the  other  five  died.  In  the  American 
w'ar  the  operation  was  done  eleven  times :  in  two  cases,  one  primaiy,  the 
other  secondary,  recovery  took  place;  nine  deaths  resulted,  chiefly''  from 
py^remia.  In  three  cases  in  which  the  patella  alone  was  excised,  death 
ensued.  During  the  late  war  the  results  of  excision  of  the  knee,  both 
primary  and  secondary’^,  have  been  so  uniformly  bad  that  the  operation 
for  the  future  will  probably'  be  abandoned  in  military'  surgery.  The  ope¬ 
ration  would  be  doubtless  advisable  in  cases  of  gun-shot  wounds  of  the 
knee  occurring  in  civil  practice,  where  every'  possible  care  and  attention 
can  be  bestowed  upon  the  after-treatment,  hygienic  conditions,  and  diet 
of  the  patient ;  but  where  this  is  impossible,  as  after  a  great  battle,  it 
is  almost  certainly  fatal,  contrasting  most  unfavorably  with  primary 
amputation  in  the  lower  third  of  the  thigh.  When  amputation  is  deter¬ 
mined  on,  the  operation  requires  to  be  performed  early^,  not  because  the 
apparent  injury  may'  be  very  severe,  or  the  mutilation  of  the  limb  so 
great  as  obviously  and  imperatively  to  call  for  immediate  amputation, 
but  because  experience  has  shown  that,  unless  the  limb  be  removed  at 
an  early  period,  after-consequences  of  the  most  serious  and  fatal  cha¬ 
racter  will  to  a  certainty'  ensue.  Extensive  suppuration  of  the  joint, 
deep  and  large  abscesses  burrowing  amongst  the  muscles  of  the  thigh, 
and  consequent  exhaustion  of  the  patient  by'  hectic,  or  his  destruction 
by"  pymmia,  are  the  conditions  that  amputation,  performed  at  an  early' 
stage,  can  alone  avert.  This  necessity  for  early  amputation  in  pene¬ 
trating  bullet-wounds  of  the  knee-joint  is  recognized  by'  all  modern 
military  Surgeons.  Guthrie  and  Larrey  in  the  French  wars,  Esmarch 
and  Stromey-er  in  the  Schleswig-Holstein  campaign,  and  the  Surgeons 


WOUNDS  OF  THE  SHOULDER. 


203 


in  the  Crimea,  all  found  that  the  attempt  to  save  a  limb  so  injured  led 
to  the  sacrifice  of  the  patient’s  life. 

Bullet-wounds  of  the  ankle-joint  do  not  necessarily  require  amputation. 
If  the  bones  be  not  too  extensively  comminuted,  and  more  particularly 
if  the  posterior  tibial  artery  and  nerve  have  escaped  injury,  an  attempt, 
and  probably  a  successful  one,  may  be  made  to  save  the  limb  ;  the  injury 
being  treated  on  those  principles  which  will  be  described  in  the  chapters 
on  Fractures  and  on  Dislocations.  In  such  cases  extraction  of  fragments, 
and  excision  of  the  splintered  ends,  are  necessary  ;  and  modified  opera¬ 
tions,  partial  excision  by  means  of  gouge,  forceps,  and  Iley’s  saw,  will  be 
found  more  successful  than  the  more  formal  operations.  If  the  large 
vessels  and  nerves  have  been  cut  across,  and  the  bones  very  extensively 
shattered,  amputation  will  be  the  proper  course  to  pursue. 

The  shoulder^  and  more  particularly  the  left  shoulder,  from  its  advanced 
position  in  the  act  of  firing,  is  peculiarly  liable  to  gunshot  injury;  the 
bullet  either  traversing  the  head  of  the  humerus,  lodging  in  it,  or  perhaps 
fracturing  some  of  the  bon}''  processes  of  the  scapula  in  its  immediate 
vicinity ;  or,  as  in  the  case  of  common  shot,  or  fragments  of  shells, 
carrying  away  the  fleshy  cushion  of  the  deltoid.  It  is  especially  in 
bullet-wounds  of  the  shoulder  and  elbow-joint,  that  conservative  surgery 
has  been  most  successful.  In  such  cases,  when  the  bones  are  penetrated, 
and  even  shattered  by  a  bullet,  provided  the  main  bloodvessels  and  nerves 
of  the  limb  be  not  injured,  amputation  will  seldom  be  required;  and, 
indeed,  it  should  be  laid  down  as  a  rule  in  surgery,  that  excision  should 
be  preferred  to  amputation  in  all  cases,  when  the  large  bloodvessels  and 
nerves  are  not  wounded,  or  the  soft  parts  too  exten¬ 
sively  disarranged.  The  wound  being  enlarged,  loose 
spicula  must  be  removed,  and  the  splintered  and  jagged 
ends  of  the  fractured  bone  sawn  smoothly  off.  If  the 
bullet  be  still  lodged  in  the  head  of  the  humerus,  as  in 
Fig.  80,  the  same  course  should  be  adopted.  It  has 
been  a  question  with  Surgeons,  whether  excision  or 
amputation  should  be  done  when  the  upper  end  of  the 
shaft  of  the  humerus  has  been  much  splintered,  with  or 
without  penetration  of  the  joint.  In  these  cases  the 
epiphysis  is  often  uninjured.  Guthrie  advised  amputa¬ 
tion  ;  but  the  result  of  the  experience  of  the  war  in 
America  has  been  that  flve  or  six  inches  of  the  shaft 
of  the  humerus  may  be  removed  with  perfect  safety,  and 
that  no  good  comes  of  leaving  the  uninjured  epiphj^sis, 
which  should  also  be  excised.  The  results  of  excision 
of  the  joints  of  the  upper  extremity  are  in  the  highest  degree  satisfactory. 
Thus  Baudens  states  that  he  saved  13  out  of  14  cases  of  excision  of  the 
shoulder.  According  to  Thornton,  in  the  British  army  in  the  Crimea, 
the  shoulder  was  excised  12  times  with  2  deaths ;  the  elbow  in  It  cases, 
of  which  2  were  fatal ;  and  partially  in  5  other  cases,  all  of  which  were 
successful.  These  results,  which  reflect  the  highest  credit  on  the  skill 
of  our  army  Surgeons,  were  more  successful  than  those  that  followed 
the  amputation  of  corresponding  parts.  Of  60  disarticulations  at  the 
shoulder,  19,  or  31  per  cent.,  were  fatal ;  and  of  153  amputations  of  the 
arm,  29,  or  19  per  cent.,  died.  The  result  of  resection  of  these  joints  has 
not  been  quite  so  satisfactory  elsewhere:  thus,  in  the  Confederate  army 
in  America,  Chisholm  states  that  up  to  February,  1864,  of  59  cases  of 
excision  of  the  shoulder,  20  proved  unsuccessful,  and  of  45  cases  in  which 
the  elbow  was  excised,  9  were  unsuccessful.  In  the  official  report  of  the 


Fig.  80. 


Bullet  ia  Head  of 
Humerus. 


204 


GUNSHOT  WOUNDS. 


Surgeon-General  of  the  United  States  army,  of  286  cases  of  excision  of 
the  elbow  in  which  the  results  are  known,  it  is  stated  that  62  died,  and 
that  in  16  amputation  became  necessary.  Of  210  primary  excisions  of 
the  shoulder-joint  death  occurred  in  50  ;  and  in  298  secondary  excisions 
in  115  cases,  giving  a  mean  mortality  of  32.48,  against  39.44  for  ampu¬ 
tation  at  the  shoulder,  and  44.4  for  eases  treated  on  the  expectant  plan. 
In  the  Russian  army,  conservative  surgery  was  also  extensively  prac¬ 
tised  ;  and  in  it,  according  to  Mouat  and  AVyatt’s  report,  of  20  cases  of 
excision  of  the  elbow,  15  recovered. 

Excision  of  the  wrist^  in  whole  or  in  part,  for  gunshot  injury  has  not 
proved  very  satisfactory,  not  so  much  from  death  as  from  inutility  of  the 
hand  that  was  left.  Of  27  done  in  the  American  war,  3  deaths  only 
occurred.  In  two  instances,  amputation  of  the  forearm  w^as  practised. 

The  steps  of  all  the  excision-operations  are  the  same,  whether  the 
excision  of  the  part  be  required  for  gunshot  injury,  or  for  other  accidents, 
or  for  disease  ;  except  that  in  gunshot  injury  advantage  may  often  be 
taken  of  the  w'ound  in  the  soft  parts,  by  enlarging  which  longitudinally, 
the  shattered  bone  may  be  readily  reached  and  extracted,  and  the 
splintered  ends  sawn  smooth. 

The  question  as  to  the  period  at  which  amputation  ought  to  he  per¬ 
formed  after  the  infliction  of  gunshot  wounds,  is  one  of  great  import¬ 
ance,  and  has  given  rise  to  much  discussion  among  Surgeons.  The  older 
military  Surgeons,  Pare,  Wiseman,  Ledran,  Ranb^}^,  etc.,  taking  a  com¬ 
mon-sense  view  of  the  question,  advocated  the  removal  of  the  hopelessly 
injured  limb  as  soon  as  possible  after  the  receipt  of  the  injury.  Wiseman’s 
advice  is  to  “  cut  off  the  limb  quickly,  while  the  soldier  is  heated  and  in 
mettle and  this  advice  has  not  been  and  cannot  be  improved  upon. 
After  the  battle  of  Fonteno}^,  in  the  middle  of  the  last  century,  pro¬ 
fessional  opinion  underwent  a  change  upon  this  subject;  and  Faure 
wrote  a  thesis,  which  obtained  a  prize  of  the  French  Academy  of  Sur¬ 
gery,  recommending  delay  in  amputating  in  certain  cases.  Hunter, 
Perc3’,  and  other  Surgeons  of  repute,  promulgated  similar  views ;  until 
Bilguer,  the  Surgeon-in-chief  of  the  armies  of  Frederick  the  Great,  went 
to  the  absurd  and  dangerous  extent  of  condemning  amputation  entirely. 
These  extreme  opinions  necessarily  occasioned  a  reaction;  and  the  expe¬ 
rience  gained  in  the  wars  of  the  French  Revolution  and  Empire,  has 
enabled  Surgeons  to  settle  this  question  definitely.  It  is  more  particu¬ 
larly  through  the  labors  and  observations  of  John  Bell,  Larre^q  Thomson, 
Guthrie,  S.  Cooper,  and  Hennen,  that  the  necessity  of  having  recourse  to 
immediate  amputation  in  ail  cases  of  gunshot  injury  requiring  this  ope¬ 
ration  has  been  fully  recognized,  and  the  truth  of  Wiseman’s  advice  has 
been  reestablished. 

In  determining  this  point  we  must  be  guided,  partly  by  surgical  experi¬ 
ence  of  the  result  of  such  cases  left  to  nature,  and  partly  by  an  appeal 
to  facts.  In  apilhaling  to  experience  we  must,  to  use  the  forcible  lan¬ 
guage  of  Sir  Charles  Bell,  contemplate  what  will  be  the  condition  of  the 
parts  in  twelve  hours,  in  six  days,  and  in  three  months.  “In  twelve 
hours  the  inflammation,  pain,  and  tension  of  the  whole  limb,  the  inflamed 
countenance,  the  brilliant  eye,  the  sleepless  and  restless  condition  declare 
the  impression  the  injury  is  making  on  the  limb  and  on  the  constitutional 
powers.  In  six  da^^s,  the  limb  from  the  groin  to  the  toe,  or  from  the 
shoulder  to  the  finger,  is  swollen  to  half  the  size  of  the  body;  a  violent 
phlegmonous  infiammation  prevades  the  whole  ;  serous  effusion  has  taken 
place  in  the  whole  limb ;  and  abscesses  are  forming  in  the  great  beds  of 
cellular  texture  throughout  the  whole  extent  of  the  extremity.  In  three 


PERIOD  FOR  PERFORMING  AMPUTATION. 


205 


months,  if  the  patient  have  labored  through  the  agony,  the  bones  are 
carious ;  the  abscesses  are  interminable  sinuses ;  the  limb  is  undermined 
and  everywhere  unsound  ;  the  constitutional  strength  ebbs  to  the  lowest 
degree.” 

If  we  appeal  to  facts,  we  shall  find  that  of  300  secondary  amputations 
reported  by  Faure,  after  the  battle  of  Fontenoy,  only  thirty  were  suc¬ 
cessful  ;  whereas  Larrey  saved  three-fourths  of  his  primaiy  amputations 
in  the  Napoleonic  wars.  In  the  Peninsular  war,  the  comparative  loss 
after  secondary  amputations  of  the  lower  extremity  was,  to  that  follow¬ 
ing  the  primary,  as  twelve  to  one ;  and  of  the  lower  extremity,  the  loss 
after  secondary  amputation  was  three  times  as  great  as  after  primary. 
During  the  siege  of  Sebastopol,  among  80,000  wounded  Russians  there 
were  3000  amputations.  Of  the  primaiy  amputations  of  the  upper  ex- 
tremit}',  leg,  and  foot,  about  one-half,  and  of  the  lower  and  middle  third 
of  the  thigh,  about  one-third  recovered  ;  but  of  all  the  secondary  ampu¬ 
tations  more  than  two-thirds  died.  Primary  amputation,  therefore, 
should  always,  when  practicable  and  imperative,  be  performed  in  prefer¬ 
ence  to  secondary. 

But  how  soon  after  the  infliction  of  the  injury  should  it  be  practised  ? 
It  is  the  opinion  of  some  Surgeons  that  there  is  often  an  interval 
between  the  infliction  of  the  injury  and  the  supervention  of  the  shock  to 
the  system,  in  which  the  limb  may  more  advantageously  be  removed. 
Should  the  depression  of  “  shock”  have  come  on,  it  then  becomes  a 
question  whether  immediate  amputation  should  be  practised,  or  the 
removal  of  the  limb  delayed  until  reaction  sets  in.  On  this  point  it  is 
obviouslj’'  difficult  to  la}’’  down  any  very  definite  rule  ;  but  it  may,  I 
think,  be  stated  generally  as  a  result  of  the  experience  of  the  best  army 
Surgeons,  that,  if  the  shock  be  not  very  intense,  the  limb  may,  under 
chloroform,  be  safely  removed.  Should  the  prostration  be  excessive, 
and  there  be  reason  to  fear  the  possibility  of  internal  injury,  it  will  be 
wiser  to  delay  operation.  But  if  an  unsuccessful  attempt  at  the  preser¬ 
vation  of  the  limb  be  made,  and  if  occasion  for  its  subsequent  removal 
should  arise,  the  Surgeon  must  wait  until  suppuration  has  set  in  before 
he  operates,  the  period  of  acute  inflammatory  action  being  allowed  to 
pass  by.  The  cases  that  most  commonly  require  secondary  amputation 
are  those  in  which  traumatic  gangrene  has  set  in  ;  here  the  limb  must 
always  be  removed  without  delay  in  accordance  with  the  principles  laid 
down  in  speaking  of  this  subject  in  reference  to  contused  wounds.  If 
profuse  hemorrhage  from  the  wound  occur,  and  do  not  admit  of  sup¬ 
pression  by  the  ordinary  means,  secondary  amputation  may  become 
necessary.  So,  also,  when  the  bones  do  not  unite,  the  patient  being 
worn  out  by  discharges  and  irritation  of  necrosis  and  caries,  and  left 
with  a  wasted,  shattered,  and  useless  limb,  its  removal  is  the  only  means 
of  saving  life.  The  great  mortality  after  secondary  amputation  in  mili¬ 
tary  practice  is,  in  great  measure,  doubtless  owing  to  the  unfavorable 
hygienic  conditions  to  which  the  wounded  soldier  is  usually  exposed 
from  overcrowding  and  want  of  necessary  appliances.  He  is  thus  pecu¬ 
liarly  liable  to  the  occurrence  of  pyaemia,  sloughing  phagedaena,  etc. 

The  nature  and  treatment  of  gunshot  injuries  of  special  regions,  as 
of  the  head,  chest,  and  abdomen,  wdll  be  considered  in  the  Chapters 
devoted  to  the  description  of  Injuries  of  those  parts. 


206 


POISONED  WOUNDS. 


CHAPTER  XI. 

POISONED  WOUNDS. 

A  VERY  important  variety  of  wound  is  that  in  which  a  poison  is  intro¬ 
duced.  The  most  important  of  these  poisoned  wounds  are  those  inflicted 
by  the  stings  of  insects,  the  bites  of  snakes  or  of  rabid  animals,  and 
injuries  received  in  dissection. 

Stings  of  Insects,  as  of  bees,  wasps,  mosquitos,  gnats,  etc.,  though 
painful,  seldom  produce  any  serious  inconvenience;  yet  occasionally 
they  may  do  so,  and  even  prove  fatal,  by  inducing  eiysipelas  in  some 
unhealthy  constitutions,  or  by  giving  rise  to  intense  irritation  from  the 
multiplicity  of  the  stings,  as  when  bees  in  great  numbers  swarm  upon  and 
sting  a  person  ;  or  they  may  be  dangerous  in  consequence  of  an  impor¬ 
tant  part  being  stung,  as  the  eye,  or  the  interior  of  the  mouth,  or  pha¬ 
rynx,  as  has  happened  from  swallowing  a  bee  in  a  piece  of  honeycomb. 
Mosquito-bites  are  peculiarly  irritating,  and  when  numerous  poison  the 
blood,  producing  nervous  depression  and  great  febrile  irritation.  Some 
insects,  as  scorpions,  or  the  tarantula  in  Italy,  give  rise  to  more  serious 
and  even  fatal  disturbance  by  their  bite.  A  peculiar  train  of  nervous 
phenomena  is  said  to  follow  the  bite  of  the  tarantula,  hence  called 
“tarantismus;”  a  disease  that  is  generally  stated  to  be  peculiarly  influ¬ 
enced  by  music,  though  this  has  been  denied  by  Gozzo. 

Treatment. — In  the  treatment  of  stings  of  insects  the  application  of 
cooling  lotions,  of  a  cold  poultice,  or  rubbing  the  part  with  olive  oil,  will 
be  found  the  most  useful  means  of  allaying  irritation.  In  some  cases, 
more  especially  in  mosquito  bites,  touching  the  part  stung  with  strong 
liquor  ammonise  or  eau-de-luce  gives  immediate  relief,  if  applied  at  once. 
In  the  case  of  stings  from  wasps  or  bees,  it  should  be  ascertained  that 
the  stinoj  has  not  been  left  in  the  wound. 

Snake-Bites  are  seldom  fatal  in  England;  venomous  reptiles,  such 
as  the  viper  and  adder,  not  possessing  sufficiently  energetic  poison  to 
destroy  a  healthy  adult,  though  they  might  possibly  kill  a  child  or  a 
very  delicate  and  weakly  person.  They  are  said  to  be  most  active  in 
warm  weather  and  during  the  season  of  procreation,  and  their  bites  are 
most  dangerous  if  inflicted  through  a  vein  or  glandular  part,  or  near  the 
centre  of  the  circulation,  or  about  the  neck  and  face.  In  tropical  coun¬ 
tries  the  bite  of  the  rattle-snake,  of  the  cobra  di  capello,  the  puff-adder, 
or  the  tobacco-pipe  snake,  is  often  fatal ;  and  it  occasionally  happens 
even  in  this  country,  that  the  surgeon  has  an  opportunity  of  seeing 
wounds  inflicted  by  these  fearful  reptiles  in  menageries.  Thus,  Sir 
E.  Home  has  recorded  a  fatal  case  of  rattle-snake  bite  occurring  in 
England.  A  similar  instance  has  occurred  at  St.  George’s  Hospital, 
and  another  in  Paris,  to  showmen.  The  most  remarkable  case  of  this 
kind  with  which  I  am  acquainted  occurred  some  3"ears  ago  at  the  Uni¬ 
versity^  College  Hospital,  aflbrding  an  opportunity,  rare  in  this  country, 
of  witnessing  the  effects  of  the  bite  of  a  cobra  di  capello.  The  patient,  a 
keeper  at  the  Zoological  Gardens,  was  bitten  in  the  bridge  of  the  nose, 
the  poison-fang  having  apparently  penetrated  the  angular  vein.  When 


SNAKE-BITES. 


207 


brought  to  the  hospital,  about  half  an  hour  after  the  accident,  he  "was 
apparently  dying,  being  unable  to  speak,  swallow,  or  support  himself ; 
the  pupils  were  dilated,  the  face  livid,  the  heart’s  action  feeble,  and  he 
was  scarcely  conscious.  After  death,  which  took  place  in  little  more 
than  an  hour  from  the  time  of  the  infliction  of  the  wound,  the  veins  of 
the  brain  and  the  cerebral  sinuses  were  found  congested  with  blood,  as 
were  also  the  lungs  to  an  immense  extent,  and  the  solid  abdominal 
viscera.  The  right  cavities  of  the  heart  were  loaded  with  dark  blood, 
the  left  being  empty;  indeed,  the  phenomena  of  asphyxia  were  strikingly 
marked.  In  this  case,  death  would  appear  to  have  resulted  from  the 
poison  paralyzing  the  medulla  oblongata,  and  those  portions  of  the  ner¬ 
vous  system  which  are  instrumental  in  carrying  on  respiration,  at  the 
same  time  that  the  blood  was  disorganized  by  the  action  of  the  virus. 

Effects  of  Snake-Poison. — The  venom  of  the  cobra  has  been  found  to 
consist  of  an  albuminous  fluid  of  acid  reaction,  holding  cells  in  suspen¬ 
sion.  When  given  internally,  or  applied  to  the  conjunctiva,  it  fails  to 
kill.  Snake-poison,  when  introduced  into  the  system  through  a  bite  or 
puncture,  may  prove  injurious  or  kill,  either  by  its  primary  and  direct 
depressing  influence  on  the  nervous  system,  somewhat  resembling  that 
produced  by  some  narcotic  poisons;  or,  secondarily  and  more  remote^, 
by  exciting  severe  diffuse  inflammation  of  the  areolar  tissue  of  the  limb 
or  part.  The  intensity  of  its  effects  depends  in  some  measure  upon  the 
vigor  of  the  animal  inflicting  the  wound;  one  that  has  been  compelled  to 
bite  frequently  has  no  longer  the  destructive  jDower  which  it  had  when 
fresh. 

The  first  mode  of  death  occurs  only  when  the  poison  is  either  very 
powerful,  or  the  animal  bitten  small.  Thus  the  poison  of  the  tobacco- 
pipe  snake  is  said  to  be  so  virulent,  that  it  will  kill  a  full-grown  man  in 
less  than  a  quarter  of  an  hour.  The  rattle-snake,  and  the  cobra  di  ca- 
pello,  will  kill  a  small  animal  in  the  course  of  a  few  seconds;  and  a  man, 
bitten  some  years  ago  by  a  rattle-snake  in  Paris,  died  in  nine  hours; 
the  cobra  bite  just  related  was  fatal  in  little  more  than  one  hour,  and 
the  Australian  tiger-snake  will  kill  in  less  than  twenty-four  hours. 

In  other  cases  the  poison  acts  by  exciting  diffuse  inflammation,  sup¬ 
puration,  &c.,  of  the  areolar  tissue.  Thus,  in  the  case  which  occurred  in 
St.  George’s  Hospital,  the  patient  died  on  the  eighteenth  da}^  after  the 
bite  of  a  rattle-snake,  with  large  abscesses  in  the  arm  and  in  the  axilla, 
and  with  sloughing  of  the  areolar  tissue  of  the  limb. 

The  Symptoms  occurring  after  a  poisonous  snake-bite  consist  in  great 
depression  and  prostration  of  the  S3’stem,  a  feeble  and  intermittent  pulse, 
dilated  pupils,  usually  slight  delirium,  indistinctness  of  speech,  at  times 
complete  aphasia,  speedy-  stupor,  insensibility,  and  death.  The  pain  is 
burning  and  lancinating,  while  the  part  bitten  swells  and  becomes  livid 
in  a  few  hours;  and  if  the  patient  survive  sufficiently  long,  diffuse 
inflammation  and  gangrene  occur  in  its  neighborhood;  involuntary 
evacuations  take  place;  asthenic  s^miptoms  set  in,  which  may  eventually 
terminate  fatally  in  the  wa}^  that  has  already  been  mentioned,  or  end 
slowly,  and  after  a  lapse  of  time,  in  the  recoveiy  of  the  patient,  whose 
health  may  long  suffer  seriousl}’’  from  the  effects  of  the  accident. 

The  Treatment  of  these  injuries  is  local  and  general. 

The  Local  Treatment  can  onljr  be  fulfilled  with  success  when  the  pa¬ 
tient  is  seen  immediatelj’  after  the  accident,  as  the  absorption  of  the 
poison  is  very  rapid.  It  presents  two  great  indications:  1,  to  prevent 
the  absorption  of  the  poison  into  the  s^^stem;  and  2,  to  treat  the  diffuse 
inflammation  and  sloughing  that  maj^  subsequently  occur.  The  first 


208 


POISONED  WOUNDS. 


indication  ma}’’  be  fulfilled  by  tying  a  ligature  so  tightly  round  the 
limb  at  a  little  distance  above  the  injured  part,  as  to  arrest  all  circulation 
through  it.  In  this  way  the  absorption  of  the  poison  may  be  prevented; 
the  wound  should  then  be  freely  cauterized  with  a  red-hot  iron  or  cinder, 
or  better  still,  be  excised,  and  a  cupping-glass  applied  over  the  cut  sur¬ 
face,  so  as  to  withdraw  the  blood  in  the  neighborhood  which  may  have 
become  contaminated  by  the  poison.  If  a  cupping-glass  be  not  at  hand, 
or  if  the  part  bitten  be  so  situated  as  not  to  admit  of  its  application, 
there  can  be  no  objection  to  the  employment  of  suction  by  the  mouth 
after  free  excision  ;  the  poison  not  being  absorbed  by  an  unbroken  mucous 
membrane.  In  using  suction,  the  mouth  should  be  rinsed  with  brandy. 
With  the  view  of  lessening  the  swelling,  tension,  and  pain  of  the  limb, 
frictions  with  olive  oil  are  said  to  be  advantageous.  After  diffuse 
inflammation  has  set  in,  this  must  be  treated  on  general  principles — by 
fomentations  and  free  incision. 

The  Constitutional  Treatment  consists  in  the  early  and  free  adminis¬ 
tration  of  the  most  powerful  stimulants,  with  a  view  of  combating  the 
depression  that  exists.  For  this  purpose,  brandy,  wine,  ammonia,  or 
ether  must  be  freely  given.  The  eau  de  luce — which  enjoys  a  high  repu¬ 
tation  in  some  tropical  countries — owes  its  efficacy  to  the  ammonia  which 
it  contains.  Should  drowsiness  come  on,  the  patient  must  be  walked 
about ;  the  artificial  respiration  with  galvanism  may  be  resorted  to  as  a 
last  means  of  maintaining  life  until  the  effects  of  the  stimulants  may 
overcome  those  of  the  poison.  Enforced  exercise — the  patient  being 
made  to  run  for  some  distance  behind  a  carriage  driven  at  a  steady 
pace — is  another  means  of  keeping  up  the  respiration,  while  the  sweating 
aids  in  the  elimination  of  the  poison.  Large  doses  of  arsenic  have  been 
recommended  as  a  kind  of  specific,  and  the  “  Tanjore  pill,”  a  celebrated 
Indian  remedj^,  owes  its  activity  to  this  mineral;  but  care  must,  of 
course,  be  taken  in  administering  this,  lest  the  remedy  prove  as  fatal  as 
the  injury  for  which  it  is  administered.  Halford,  of  Melbourne,  has 
used,  in  cases  of  bite  by  the  “  brown  snake,”  a  very  venomous  kind, 
whose  bite  is  nearly  alwa3^s  fatal,  an  injection  of  strong  solution  of 
ammonia,  diluted  with  twice  its  bulk  of  water,  into  a  superficial  vein, 
such  as  the  radial.  Fifteen  or  thirty  minims  are  thrown  in,  and  repeated 
accordino;  to  circumstances.  The  effect  is  described  to  be  an  immediate 
rousing  of  the  patient  from  his  stupor.  Fayrer,  of  Calcutta,  however, 
finds  that  this  remedy  has  no  power  in  cases  of  cobra  bite.  As  liquor 
potassse  decomposes  the  virus  into  a  sediment  and  supernatant  fluid, 
both  of  which  are  innocuous,  it  might  be  supposed  that  it  would  act  as 
a  true  antidote,  but  it  has  not  been  found  to  do  so  when  injected  into 
the  blood  of  bitten  animals. 

Bites  of  Rabid  Animals  give  rise  to  the  disease  so  much  and  so 
justl}^  dreaded,  but  fortunately  seldom  seen  in  man  in  this  country, 
termed  Hydrophobia. 

This  disease  cannot  originate  de  novo  in  man,  but  invariably  occurs  in 
him,  and  most  commonly  in  the  lower  animals,  as  the  result  of  contagion. 
Animals  of  the  canine  and  feline  species  are  most  subject  to  it ;  especially 
the  dog,  the  wolf,  the  fox,  the  jackal,  and  the  cat.  It  has  not,  I  believe, 
been  observed  in  lions  or  tigers,  or  the  larger  feline  animals.  When 
originating  de  novo  in  animals,  its  causes  are  excessively  obscure.  It 
has  been  attributed  to  the  influence  of  season ;  thus  Eckel  found  it  most 
common  in  dogs  in  February  and  Ma}’’.  Want  of  water,  sudden  changes 
from  heat  to  cold,  bad  food,  and  unsatisfied  sexual  desire,  have  also 
each  been  assigned  as  causes  of  its  occurrence  in  animals.  When  we 


HYDROPHOBIA. 


209 


inquire  into  the  operation  of  these  alleged  causes,  we  fail  to  discover 
any  direct  and  positive  connection  between  any  one  of  them  and  rabies. 
With  regard  to  the  influence  of  heat  and  want  of  water,  it  would  appear 
that  in  those  countries  in  which  animals  of  the  canine  and  feline  races 
are  most  exposed  to  these  conditions  hydrophobia  is  unknown.  Thus, 
Mr.  Donovan,  who  has  resided  and  travelled  for  many  3’ears  in  Central 
Africa,  informs  me  that,  in  the  deserts  of  that  countiy,  where  water  is 
so  scarce  that  man  and  beast  often  die  of  thirst,  lions  are  always  to  be 
found  and  are  occasionally  seen  going  about  in  families,  whilst  h3^enas, 
jackals,  and  wild  dogs  are  most  numerous,  and  yet  hydrophobia  is 
unknown.  Barrow,  a  scientific  and  observant  traveller,  makes  a  similar 
statement,  viz.,  that  hydrophobia  cannot  proceed  from  thirst  and  heat, 
as  it  is  unknown  in  Eg3q^t,  the  West  India  Islands,  and  some  other 
tropical  parts.  The  theoiy  of  ly^drophobia  arising  from  ungratified 
sexual  desire  appears  to  be  equally  untenable.  It  is  not  uncommon  in 
Africa,  Mr.  Donovan  sa3"s,  for  wolves,  jackals,  and  wild  dogs  to  prowl 
about  mad  with  heat ;  and  in  this  state  they  are  most  dangerous,  so 
much  so  that  domesticated  dogs  instinctively  shun  them,  but  there  is  no 
evidence  of  their  ever  having  communicated  ly’drophobia.  Having  been 
told  that  no  bitches  were  allowed  in  Sark,  I  wrote  to  Dr.  Cockridge  of 
that  Island  to  inquire  if  this  were  the  fact,  and  if  so,  wdiether  h3'dro- 
phobia  were  prevalent  there.  He  informed  me  that  there  were  no  bitches 
in  the  island,  and  that  dogs  were  very  numerous,  but  that  no  case  of 
hydrophobia  had,  to  his  knowledge,  ever  occurred  there,  and  that  the 
clerg3'man,  who  had  had  thirt3"  3’ears’  exiDerience  of  the  island,  had  never 
heard  of  a  case  of  that  disease.  Dogs  more  frequentl3^  become  rabid 
than  bitches;  thus,  of  a  hundred  and  fort3’-one  cases  collected  by  Eckel, 
onl3’  fifteen  occurred  in  bitches  ;  and  amongst  dogs  it  is  most  common 
in  those  of  a  mongrel  breed,  seldom  affecting  those  that  are  of  pure  blood, 
or  that  have  been  castrated.  In  the  human  sulqect  it  never  appears 
except  as  the  result  of  contagion  either  b3’  a  bite,  or  by  the  rabid  animal 
licking  a  raw  surface,  as  an  abrasion  on  the  hand  or  lip.  The  bite  of  a 
rabid  animal  is  most  dangerous  when  inflicted  on  a  naked  part,  as  on  the 
hand  or  face.  A  person  bitten  through  clothing  often  escapes  an3’  ill 
effects,  in  consequence  of  the  teeth  being  wiped  and  the  poisonous  saliva 
arrested  by  the  clothes.  Hence  a  number  of  persons  may  be  bitten  b3’ 
the  same  rabid  animal,  and  but  a  very  few  take  the  disease  ;  not  more, 
perhaps,  than  one  in  ten  or  twent3’.  H3'drophobia  ma3'  occur  1)3^  the 
inoculation  of  a  wound,  and  not  by  a  bite  01113^  Thus  it  has  been  known 
to  be  developed  b3^  a  lap-dog  licking  the  lip  of  a  lady,  on  which  there 
was  a  crack. 

The  period  that  intervenes  between  the  bite  and  the  occurrence  of  the 
disease  is  usually  considerable.  Meade  has  related  a  case  of  a  lad3"  who 
had  the  disease  fifteen  months  after  the  bite  ;  and  Ma3’er,  of  St.  Peters¬ 
burg,  that  of  a  3"oung  man  w’ho  died  of  hydrophobia  twent3’-six  months 
after  being  bitten.  Elliotson  says  that  the  average  time  that  elapses 
between  the  injury  and  the  S3’mptoms  is  from  six  weeks  to  three  months. 
In  the  case  of  the  Duke  of  Richmond,  who  was  bitten  bv’  a  tame  fox, 
the  disease  did  not  develop  itself  until  between  six  and  seven  weeks  after 
the  injury.  Writers,  however,  in  stating  that  six,  seven,  twelve,  and 
even  fifteen  years  have  intervened  between  the  infliction  of  the  wound 
and  the  manifestation  of  the  symptoms,  have  evidentl3^  committed  an 
exaggeration  or  fallen  into  error,  having  probably  confounded  with 
h3’drophobia  other  nervous  affections  that  closely  resemble  it. 

Symptoms. — The  wound  has  generall3’  cicatrized  long  before  any  symp- 
VOL.  I _ 14 


210 


POISONED  WOUNDS. 


toms  of  hydrophobia  declare  themselves;  and  no  peculiar  appearance  is 
presented  by  the  scar.  Shooting  pains,  twitching  and  itching  sensations 
have,  however,  occasional!}’  been  experienced  in  the  site  of  the  wound 
before  the  supervention  of  the  attack  ;  and  it  is  probable  that  in  all  cases 
some  process  analogous  to  a  zymotic  action  takes  place  within  it  before 
the  disease  comes  on.  The  precise  nature  of  this,  however,  requires  to 
be  elucidated  by  further  observation. 

The  symptoms  are  usually  ushered  in  for  two  or  three  days  (according 
to  Perry  for  five  or  six)  by  some  antecedent  phenomena,  consisting  of 
giddiness,  chills,  and  heats,  and  a  general  feeling  of  discomfort.  The 
more  special  symptoms  never  manifest  themselves  until  the  disease  is 
fairly  established ;  they  consist  essentially  in  violent  and  repeated  con¬ 
vulsive  movements  of  a  reflex  character,  induced  by  various  external 
influences  acting  on  the  surface  of  the  body  or  on  the  fauces,  or  by 
mental  impressions ;  and  they  speedily  end  in  exhaustion  and  death. 
The  special  symptoms  consist  of:  1,  Spasmodic  Affection  of  the  Mus¬ 
cles  of  Deglutition  and  Respiration ;  2,  Extreme  Sensibility  of  the 
Surface  and  of  the  Senses ;  and  3,  Excessive  Mental  Terror  and 
Agitation. 

1.  In  consequence  of  the  Spasmodic  Affection  of  the  Muscles  of  Deglu¬ 
tition^  i\\Q.  act  of  swallowing  commonly  excites  convulsions;  hence  the 
patient  experiences  a  horror  of  all  liquids ;  and,  in  attempting  to  drink, 
gulps  down  the  fluid  with  a  strong  mental  effort.  In  some  cases,  solids 
give  rise  to  the  same  difficulty  in  deglutition  as  liquids ;  but  occasion¬ 
ally,  though  rarely,  patients  have  been  known  to  swallow  perfectly  well 
throughout  the  disease.  This  difficulty  in  swallowing  is  certainly  owing 
to  an  excessive  sensibility  about  the  pharynx  and  throat,  in  consequence 
of  which  every  effort  at  deglutition  induces  violent  reflex  convulsive 
movements  in  all  the  muscles  and  parts  supplied  by  the  pneumogastric 
nerve. 

A  catch  in  the  breathing,  resembling  what  often  occurs  when  a  person 
goes  into  a  cold  bath,  is  met  with  as  one  of  the  earlier  symptoms, 
taking  place  in  the  midst  of  conversation,  and  before  the  patient’s  mind 
is  directed  to  the  nature  of  the  disease.  This  catch  is  due  to  the  spas¬ 
modic  descent  of  the  diaphragm,  and  gives  rise  to  severe  pain  at  the 
pit  of  the  stomach,  or  to  a  feeling  of  suffocation  and  a  return  of  the 
convulsions.  In  consequence  of  this  spasm  of  the  diaphragm,  the 
patient  makes  from  time  to  time  a  loud  hiccuping  noise,  which  has  been 
likened  to  the  bark  of  a  dog. 

2.  Excessive  Sensibility  of  the  Cutaneous  Nerves^  and  of  some  of  the 
Nerves  of  Special  Sense^  is  characteristic  of  hydrophobia.  The  cuta¬ 
neous  nerves  become  so  sensitive  that  a  blast  of  cold  air,  the  rustling 
of  the  bedclothes,  the  slightest  touch  of  or  movement  on  the  skin,  will 
bring  on  convulsions.  The  nerves  of  sense  become  equally  excitable, 
so  that  a  sudden  flash  of  light  before  the  eyes,  as  the  reflection  of  the 
sun  from  a  looking-glass,  or  a  sudden  noise,  as  the  slamming  of  a  door, 
will  produce  the  same  effect.  The  noise  produced  by  liquids  being 
poured  from  one  vessel  to  another  is  peculiarly  distressing  to  the 
patient ;  and  Elliotson  mentions  a  case  in  which  a  patient  with  hydro¬ 
phobia  was  thrown  into  violent  agitation  by  hearing  the  dresser  who 
sat  up  with  him  void  urine.  The  sufferings  and  convulsions  that  patients 
experience  when  they  attempt  to  drink  appear  to  be  owing  to  excessive 
sensibility  of  the  nerves  of  the  mouth  and  pharynx,  and  the  recollection 
of  these  sufferings  makes  them  afraid  to  repeat  the  attempt ;  hence  the 
fear  of  liquids  from  which  the  disease  derives  its  name. 


TREATMENT  OF  HYDROPHOBIA. 


211 


3.  One  of  the  earliest  s3"mptoms,  and  one  of  the  most  persistent,  is 
extreme  Mental  Agitation  and  Terror^  a  vague  sense  of  dread  and 
horror  at  the  impending  fate.  Spectral  delusion  sometimes  occurs,  the 
patient  supposing  himself  to  be  surrounded  animals,  b}"  horrid  forms, 
or  by  gaping,  ghastl}",  and  grinning  countenances,  by  flies  or  wasps. 
The  first  sj’inptom  in  the  Duke  of  Richmond’s  case  was,  that  he  fancied 
some  poplar-trees  opposite  his  bedroom  window  to  be  men  looking  in. 
These  delusions  ma^’’  alternate  with  fits  of  delirium,  terror,  and  frenzy. 
In  these  it  is  said  that  the  patient  barks  like  a  dog,  and  endeavors  to 
bite  ;  but  this  is  a  popular  error — the  pretended  bark  is  merely' the  catch 
in  breathing,  and  the  attempt  to  bite  is  nothing  but  movements  of  the 
tongue  and  mouth  induced  by  the  clamminess  of  the  viscid  and  ropy 
saliva. 

Occasional!}’’  the  s^’mptoms  subside  completely  before  death ;  the  sen¬ 
sibility  of  the  surface  disappearing,  the  mental  agitation  or  delusion 
being  removed,  and  deglutition  and  respiration  being  quieth'  performed. 
Thus,  Latham  relates  the  case  of  a  man  laboring  under  this  disease, 
who  sat  up  quietl}^  in  bed  and  drank  a  pint  of  porter  half  an  hour  before 
he  died. 

Prognosis. — I  am  not  acquainted  with  an}^  case  of  recovery  from 
h^’drophobia,  after  the  disease  has  fairl}'  set  in.  It  cannot,  however,  be 
pronounced  to  be  absolutel}^  and  inevitably  fatal ;  for  Radcliffe  states 
that,  of  109  authentic  cases,  recovery  took  place  in  14.  The  disease 
may  prove  fatal  in  four-and-twenty  hours,  or  life  ma}^  be  prolonged  for 
six  or  seven  daj's  ;  death  generall}'  occurring  from  the  second  to  the 
fourth  day,  and  being  apparentl}"  induced  b}^  exhaustion. 

Pathology. — The  appearances  found  after  death  throw  no  light  what¬ 
ever  upon  the  disease,  and  indeed  ma}’  often  be  supposed  to  be  simply 
the  effects  of  the  spasmodic  irritation.  The  tongue,  the  fauces,  the 
throat,  the  glottis,  and  the  laiynx,  the  stomach  and  oesophagus,  the 
brain,  the  medulla  oblongata,  and  spinal  cord,  have  all  been  found  con¬ 
gested  and  inflamed  ;  there  is  nothing,  however,  in  the  appearances  pre¬ 
sented  by  these  parts  that  affords  a  clue  to  the  true  nature  of  this 
inscrutable  and  terrible  malad}'.  In  fact,  eveiything  connected  with 
hydrophobia  is  at  present  involved  in  complete  obscurit}*.  We  neither 
know  what  occasions  rabies  in  the  dog,  nor  in  what  consists  the  change 
in  his  secretions,  that  enables  him  to  transmit  the  disease  to  man 
Equall}*  obscure  are  the  processes  that  are  going  on  at  the  seat  of  the 
wound  or  in  the  constitution  generall}^,  during  the  period  that  inter¬ 
venes  between  the  infliction  of  the  bite  and  the  development  of  the  dis¬ 
ease;  and  lastly,  pathological  research  has  hitherto  failed  to  throw  the 
faintest  glimmer  of  light  on  the  nature  of  the  changes  which  the  nervous 
system  undergoes,  and  which  occasion  the  characteristic  phenomena  of 
h^^drophobia. 

Treatment. — This  must  be  principall}’’ prevcuh'ue  and  We 

cannot  speak  of  curative  treatment  of  h3’drophobia ;  for,  after  the  dis¬ 
ease  has  once  set  in,  the  utmost  that  can  be  done  will  not  accomplish 
more  than  to  lessen  the  suflferings  of  the  patient,  and  sta}"  for  a  few 
hours  the  almost  inevitabl}’^  fatal  termination. 

When  a  person  is  bitten  by  a  dog  that  is  mad,  or  even  b}"  one  that  is 
supposed  to  be  so,  the  Surgeon  should  alwa3’s  adopt  energetic  means  to 
save  the  patient  from  the  invasion  of  a  disease  that  is  necessaril}'  fatal. 
In  having  recourse  to  preventive  treatment,  it  should  be  borne  in  mind 
that  the  larger  proportion  of  persons  actually  bitten  b}'  rabid  animals 
do  not  fall  victims  to  h3^drophobia ;  the  probabilit}^  of  the  occurrence  of 


212 


POISONED  WOUNDS. 


the  disease  depending  partly  upon  the  animal  that  bites,  and  partly 
upon  whether  the  bite  is  inflicted  on  the  naked  or  on  the  clothed  part 
of  the  body.  Thus  TTatson  states  that,  of  114  persons  bitten  b}"  mad 
wolves,  67  died  of  hydrophobia ;  whilst,  according  to  Hunter  and 
Vaughan,  only  one  out  of  20  or  30  bitten  b}^  mad  dogs  takes  the  dis¬ 
ease.  The  latter  estimate  may  possibly  be  somewhat  lower  than  the 
truth  ;  vet  the  fact  remains  certain  that  wolf-bites  are  far  more  danorerous 
than  dog-bites,  and  this  is  probablj’  owing  to  the  circumstance  of  wolves 
always  flying  at  the  face  and  naked  parts.  It  is  in  consequence  of  this 
small  proportion  of  persons  taking  the  disease  out  of  the  total  number 
bitten,  that  so  man}’  popular  remedies  and  superstitions  have  obtained 
an  unmerited  reputation  for  preventing  the  disease.  The  only  preventive 
means  that  can  be  trusted  to  by  a  Surgeon,  are  excision  and  caustic. 

Excision  of  the  part  bitten  should  be  carefull}’  and  freely  performed, 
no  half  measures  being  had  recourse  to.  Hence  it  is  better  to  remove 
too  much  of  a  comparatively  unimportant  tissue  or  part,  than  to  allow 
the  sufierer  to  run  anv  risk  of  falling  a  victim  to  the  fatal  disease.  In 
order  to  excise  eveiy  part  that  has  been  touched  by  the  tooth,  the  Sur¬ 
geon.  after  washing  the  wound  and  contiguous  surface  with  strong  car- 
bolic  acid  lotion,  should  make  a  circle  with  ink,  or  tincture  of  iodine, 
completely  round  tlie  injured  part.  He  must  then  pass  a  probe  to  the 
bottom  of  the  wound,  and  excise  the  whole  by  scooping  out  a  conical 
piece  of  the  tissues,  taking  care  to  go  beyond  the  furthest  limit  to  which 
the  i)robe  is  passed.  If  there  be  any  doubt  of  the  whole  of  the  injured 
parts  having  been  removed,  potassa  fusa  should  be  applied.  If  the  lip 
be  bitten  through,  a  portion  should  be  cut  out,  and  the  wound  brought 
together,  as  in  harelip  operations;  if  a  finger  be  injured,  it  should  be 
amputated.  When  the  wound  is  so  situated  that  excision  cannot  readily 
be  performed,  potassa  fusa,  or  strong  nitric  acid,  or  nitrate  of  silver,  as 
recommended  by  Youatt,  should  be  freel}’  applied  to  every  corner  of  it. 
If  the  wound  have  already  cicatrized,  the  bitten  part  should  be  excised 
at  any  time  after  the  injuiy,  provided  the  dog  is  known  to  have  been, 
or  to  have  become  mad  ;  for  it  is  not  improbable  that,  in  the  cases  where 
the  disease  has  occurred  at  a  remote  period,  it  has  been  dependent 
upon,  or  connected  with,  some  peculiar  action  set  up  in  the  wound,  which 
might  {)Ossibly  be  averted  by  the  removal  of  the  cicatrix. 

I  forbear  to  speak  of  an}*  other  means  of  preventive  treatment,  as  I 
consider  them  utterly  undeserving  of  confidence. 

After  the  disease  has  once  set  in,  nothing  can  be  done  but  io  palliate 
symptoms  and  prolong  life.  Every  possible  remedy  that  the  ingenuity 
of  man  could  devise,  from  warm  water  to  viper-  and  ticuna-poison,  has 
been  tried,  and  been  found  utterly  useless.  The  only  plan  of  treatment 
that  holds  a  hope  of  eventual  success,  and  which,  whether  it  succeed  or 
not  in  curing  the  patient,  at  all  events  mitigates  his  sufferings,  is  that 
which  has  been  recommended  by  Marshal  Hall  and  Todd.  It  consists, 
in  the  first  place,  in  removing  all  external  irritation,  w’hether  mental  or 
bodily ;  putting  the  patient  in  a  darkened  room,  as  much  removed  as 
possible  from  all  noise  and  the  intrusive  curiosity  of  strangers,  and  sur¬ 
rounding  his  bed  with  gauze  curtains  or  screens,  so  as  to  prevent  the 
disturbing  influence  even  of  a  draught  of  cold  air.  Measures  must  then  be 
adopted  to  lessen  the  excitability  of  the  spinal  cord  :  this  may  be  done 
most  efficiently,  as  Todd  suggests,  by  the  application  of  ice  in  a  piece 
of  gut  laid  along  the  whole  length  ofl  the  spine.  Lastly,  the  Surgeon 
must  bear  in  mind  that  he  has  to  treat  an  exhausting  disease,  and  that  he 


DISSECTION  WOUNDS. 


213 


must  consequently  support  the  patient  by  wine,  beef-tea,  and  such 
nourishment  as  can  be  taken. 

Wounds  with  Ii^oeulation  of  Decomposing  Animal  Matter. 

— The  majority  of  wounds  of  this  character  are  not  dangerous.  Every 
student  of  anatomy  frequently  punctures  and  cuts  himself  in  dissecting, 
but  we  rarely  see  anj'’  ill  consequences  following  these  injuries.  In  some 
cases,  however,  the  most  serious  results,  terminating  in  permanently 
impaired  health,  or  even  in  death,  ensue.  The  result  depends  fully  as 
much  on  the  state  of  health  of  the  person  punctured,  as  on  the  condition 
of  the  bod}^  from  which  the  puncture  is  received.  If  the  health  be 
broken  b}’’  any  cause,  whether  excess  of  stud}’’  or  dissipation,  or  over¬ 
fatigue  in  professional  work,  very  serious  effects  ma}”  follow,  which  would 
not  occur  if  the  patient  had  the  resisting  power  of  a  sound  and  strong 
constitution. 

Causes. — The  deleterious  influence  exercised  b3'the  dead  body,  human 
or  brute,  may  be  attributed  to  three  different  causes:  1,  the  mere  ordinary 
Irritation  of  the  Wound;  2,  Inoculation  of  Putrid  Matter;  or,  3,  Intro¬ 
duction  of  a  Specific  Septic  Virus  into  the  system.  I  think  it  probable 
that  each  of  these  causes  may  exercise  an  influence,  but  that  the  worst 
effects  of  dissection-wounds  are  dependent  on  the  inoculation  of  a  pecu¬ 
liar  and  specific  virus. 

1.  That  ill  effects  sometimes  result  from  the  Irritation  of  the 

Puncture evident  from  the  fact  that  mere  scratches  or  punctures  with 
splinters  of  wood,  or  other  harmless  substances,  give  rise  to  considerable 
local  disturbance  in  certain  states  of  the  constitution;  so  also  those 
dissection-wounds  which  are  ragged  and  torn,  such  as  are  made  by 
spicula  of  bone  or  the  teeth  of  the  saw,  are  peculiarl}^  troublesome. 

2.  Putrescent  Matters  must  alwa^’s  be  injurious  wiien  introduced  into 
the  econom}’ ;  but  at  the  same  time  it  is  a  remarkable  fact,  that  the 
worst  effects  of  dissection-wounds  have  resulted  from  those  received 
before  putrefaction  had  set  in,  and  that  they  more  commonly  occur  in 
post-mortem  inspections  made  a  few  hours  after  death,  than  in  dissecting- 
room  investigations  on  the  parts  in  an  advanced  stage  of  decomposition. 

3.  That  the  worst  forms  of  dissection-wounds  are  dependent  upon  a 
Specific  Septic  Virus^  is  evident  from  the  fact  that  it  is  especially  after 
death  from  certain  diseases,  especially  of  an  eiTsipelatous  or  pyaemic 
type,  that  these  consequences  ensue.  Most  danger  is  to  be  apprehended 
from  punctures  received  from  the  bodies  of  those  who  die  of  erysipelas, 
phlebitis,  p3’8emia,  and  the  diffused  forms  of  peritonitis  following  partu¬ 
rition  or  the  operation  of  hernia.  And  it  is  veiy  important  to  observe 
that  putrefaction  is  by  no  means  necessaiy  for  this.  The  greatest  dan¬ 
ger  exists  before  putrefaction  sets  in.  A  few  hours  after  death,  whilst 
still  quite  fresh,  the  bod}"  is  in  the  highest  degree  infectious  and  danger¬ 
ous ;  and  in  these  cases  I  think  that  advanced  putrefaction  rather 
lessens  than  increases  the  danger.  Indeed,  the  septic  influence  in  these 
cases  continues  after  death  to  be  capable  of  producing  iii  the  living  who 
are  inoculated  with  it,  a  distinct  infection  of  the  nature  of  septcemia. 
Of  all  these  influences,  that  which  is  generated  ly  hernial  or  puerperal 
peritonitis  is  ly  far  the  most  noxious.  The  acrid  fluid  which  accumu¬ 
lates  in  the  peritoneum  when  that  structure  is  attacked  b}^  diffuse  inflam¬ 
mation  of  the  kinds  just  mentioned,  appears  to  exercise  a  specifically 
injurious  influence.  I  believe  it  to  be  impossible  to  immerse  the  hand 
into  it  with  impunit}"  if  there  should  happen  to  be  a  scratch,  puncture, 
or  abraded  surface  of  an}"  kind  on  one  of  the  fingers.  Inoculation 
would,  under  such  circumstances,  inevitably  ensue,  followed  by  diffuse 


214 


POISONED  WOUNDS. 


inflammation  to  a  greater  or  less  extent.  It  is,  however,  by  no  means 
necessaiy  for  post-mortem  infection  that  there  be  an  abraded  or  broken 
surface  through  which  the  inoculated  matter  may  be  introduced  into  the 
system.  Imbibition  may  take  place  through  the  unbroken  cuticle;  and 
not  unfrequently  it  is  through  the  medium  of  the  hair-follicles  that  the 
septic  poison  enters.  In  the  graphic  account  given  hy  Sir  James  Paget 
of  liis  own  case,  the  septic  influence  is  stated  to  have  been  absorbed 
through  the  unbroken  cuticle  of  the  hand  immersed  in  pj’semic  pleuritic 
effusion.  I  have  known  an  instance  of  the  poisoning  through  the  hair- 
follicles  of  the  back  of  the  hand  to  happen  to  another  very  distinguished 
member  of  our  profession.  That  the  poisonous  influence  from  the  bodies 
of  persons  who  have  died  of  septic  diseases  is  transmissible  to  others  by 
contact  or  infection,  cannot  be  denied  ;  and  accoucheurs  and  operating 
Surgeons  should  abstain  as  carefully  as  possible  from  performing  post- 
mortem  examinations  on  patients  dying  from  such  diseases,  lest  the 
poisonous  influences  be  carried  to  and  excite  similar  morbid  action  in 
their  own  patients. 

Symptoms. — From  what  has  been  stated  above,  it  would  appear  that 
there  are  two  distinct  kinds  of  mischief  resulting  from  dissection-wounds. 

The  milder  form  proceeds  from  the  simple  irritation  of  a  scratch  in  a 
broken  constitution,  or  from  the  inoculation  of  non-specific  putrescent 
matter.  The  punctured  part  becomes  painful,  hot,  and  throbbing,  in 
from  twelve  to  twenty  four-hours  after  the  injury ;  the  finger  swells  and 
inflames,  the  absorbents  of  the  arm  are  perhaps  affected,  and  the  glands 
in  the  axilla  become  enlarged.  There  is  general  febrile  disturbance, 
ushered  in  by  rigors  and  a  feeling  of  depression  ;  suppuration  takes 
place  about  the  puncture,  and  also,  perhaps,  in  the  inflamed  glands,  the 
case  presenting  the  ordinary  characters  of  whitlow  with  inflammation  of 
the  absorbents. 

In  the  more  severe  form  of  dissection-wounds,  the  patient  is  seized, 
about  twelve  or  eighteen  hours  after  the  puncture,  with  rigors,  anxiety 
of  countenance,  and  depression  of  the  nervous  system ;  with  a  quick 
pulse,  and  with  inflammatory  febrile  reaction.  On  examining  tlie  finger, 
a  pustule,  or  vesicle,  with  an  inflamed  areola,  will  be  observed  in  the 
situation  of  the  puncture;  from  this  a  few  red  lines  may  be  seen  stretch¬ 
ing  up  towards  the  arm-pit,  where  there  ma^'’  be  swelling  and  tension. 
Diffuse  inflammation  of  the  areolar  tissue  of  the  limb  sets  in  about  the 
fifth  or  sixth  day,  extending  up  to  the  shoulder,  and  down  the  side  of 
the  chest  to  the  flank.  Abscesses  form,  often  with  much  pain,  in  these 
situations;  they  are  usually  somewhat  diffuse,  the  pus  being  mixed 
with  shreds  and  sloughs.  The  general  sj^mptoms  gradually  assume  an 
asthenic  type;  the  tongue  becomes  brown,  sordes  accumulate  about  the 
lips  and  gums,  low  delirium  sets  in  with  a  rapid  feeble  pulse,  and  death 
occurs  in  from  ten  days  to  three  weeks.  When  incisions  are  made  into 
the  brawny  tissue,  it  is  found  infiltrated  with  sero-pus,  and  in  a  sloughy 
state.  If  the  patient  live,  large  circumscribed  abscesses  form  under  the 
pectorals,  in  the  axilla,  and  above  the  clavicle,  with  much  exhaustion  and 
depression  of  the  system,  convalescence  being  tedious  and  prolonged, 
and  the  constitution  often  shattered  for  life. 

It  is  this  form  of  the  disease  that  resembles  diffuse  inflammation  of 
the  areolar  tissue  arising  from  other  causes;  and  indeed  there  can  be 
little  doubt  that  it  is  a  cellular  erysipelas  dependent  on  a  toxic  agency. 
That  this  form  of  dissection-wound  is  of  a  truly  erysipelatous  character, 
is  evident  from  the  fact  that  patients  laboring  under  it  will  communicate 
fatal  erysipelas  to  their  nurses  and  attendants;  as  happened  in  the  case 


I 


TREATMENT  OF  DISSECTION  WOUNDS. 


215 


of  the  late  J.  P.  Potter,  of  University  College  Hospital,  whose  early 
death  was  much  to  be  lamented.  It  is  also  this  kind  of  dissection- 
wound  that  is  especially  apt  to  occur  after  punctures,  received  from  pa¬ 
tients  who  have  died  of  diffuse  inflammation  of  the  serous  membranes. 

The  symptoms  produced  by  contact,  independently  of  any  wound  with 
the  bodies  of  persons  who  have  died  of  erysipelatous  or  p^'iemic  diseases, 
sometimes  vary,  though  still  referable  to  the  introduction  of  a  poison. 
Thus  I  have  known  a  body  to  infect  seriously  in  different  wa3"s  six 
students  who  were  working  at  it.  Two  had  suppuration  of  the  areolar 
tissue,  under  the  pectorals  and  in  the  axilla;  one  was  seized  with  a  kind 
of  maniacal  delirium ;  a  fourth  had  tv^phoid  fever;  and  the  remaining  two 
were  seriously,  though  not  dangerously  indisposed. 

Treatment. — On  the  receipt  of  a  puncture  in  dissection,  or  in  making 
a  2?ost-mortem  examination,  the  best  mode  to  prevent  injurious  conse¬ 
quences  is  to  tie  a  string  tiglitly  round  the  finger  above  the  injur}’’,  thus 
causing  the  blood  to  flow  and  perhaps  to  carry  out  the  virus  with  it. 
The  part  should  then  be  well  washed  in  a  stream  of  cold  water  at  a 
tap,  and  sucked  for  some  minutes;  in  this  wa}"  any  poisonous  matter 
that  has  been  introduced  ma}’  usiiall}'  be  got  rid  of.  It  is  better  not  to 
apply  caustics;  the}'  only  irritate  and  inflame  the  finger,  and  can  do  but 
little  good.  If  any  caustic  be  employed,  it  should  be  a  drop  of  nitric 
acid  let  fall  into  the  wound,  or  of  pure  carbolic  acid,  which  is  the  only 
escharotic  that  has  the  power  of  destroying  animal  virus.  The  nitrate 
of  silver,  which  is  commonly  employed,  can  never  do  much  good,  as  it 
does  not  penetrate  to  a  sufficient  depth  to  be  of  service.  Dissectors 
should  bear  in  mind  that  the  state  of  the  constitution  exercises  great 
influence  upon  the  effects  of  the  puncture  ;  and  that,  in  proportion  as  the 
health  is  sound  and  the  body  not  exhausted  by  over-fatigue,  there  is  less 
likelihood  of  any  injurious  consequences  ensuing. 

In  the  slighter  forms  of  dissection-wound,  attended  by  a  moderate 
amount  of  inflammation,  the  part  must  be  poulticed,  leeches  should  be 
applied,  and  the  arm  put  in  a  sling.  If  the  absorbents  become  inflamed, 
chamomile  and  poppy  fomentations  must  be  diligently  used,  abscesses 
must  be  opened  early,  and  free  incisions  should  be  made  wherever  there 
is  much  tension,  even  though  matter  have  not  already  formed,  with  a 
view  to  prevent  suppuration.  The  general  treatment  of  clearing  out  the 
bowels  with  a  free  calomel  purge,  followed  by  moderate  stimulation, 
must  be  adopted  in  the  early  stage;  but  tonics  and  strong  support  will 
soon  be  required,  and,  if  there  be  much  constitutional  irritation,  opiates 
may  advantageously  be  administered. 

The  treatment  of  the  more  severe  forms  of  dissection-injury  consists 
principally  in  fomentations,  and  in  early  and  very  free  incisions  into  the 
finger  or  other  parts  that  become  tense  and  brawny.  In  the  constitu¬ 
tional  treatment  our  great  reliance,  after  clearing  out  the  intestinal  canal 
by  a  free  purge,  consists  in  the  administration  of  bark,  ammonia,  cam¬ 
phor,  wine  and  brandy,  with  such  fluid  nourishment  as  the  patient  can 
take;  the  case  being  treated  as  one  of  the  lowest  forms  of  asthenic 
inflammation.  If  the  patient  survive,  he  must  be  sent  as  soon  as  possi¬ 
ble  into  the  country,  and  must  devote  some  months,  perhaps,  to  the 
re-establishment  of  his  health.  The  part  that  has  been  punctured  often 
continues  irritable  for  a  great  length  of  time,  even  for  many  years,  re¬ 
maining  red,  inflamed,  and  desquamating,  pustules  being,  perhaps,  some¬ 
times  formed  on  it.  This  condition  is  best  remedied  by  the  occasional 
application  of  nitrate  of  silver. 


216 


EFFECTS  OF  HEAT  AXD  COLD. 


CHAPTER  XII. 

EFFECTS  OF  HEAT  AXD  COLD. 

BURNS  AND  SCALDS. 

A  Burn  is  the  result  of  the  application  of  so  great  a  degree  of  heat  to 
the  body  as  to  produce  either  inflammation  of  the  part  to  which  it  is 
applied,  or  charring  and  complete  disorganization  of  its  tissue.  A  Scald 
is  occasioned  by  the  application  of  some  hot  fluid  to  the  body,  giving 
rise  to  the  same  destructive  effects  as  are  met  with  in  burns,  though 
dififering  from  them  in  the  appearances  produced. 

Local  EfFeets. — Burns  and  scalds  vary  greatly  in  the  degree  of  dis¬ 
organization  of  tissue  to  which  the}^  give  rise;  this  A’ariation  depending 
partR  upon  the  intensity  of  the  heat,  and  partly  upon  the  duration  of  its 
application.  The  sudden  and  brief  application  of  flame  to  the  surface 
produces  but  veiy  slight  disorganization  of  the  cuticle,  with  some  hy- 
permmia  of  the  skin.  If  the  part  be  exposed  for  a  longer  time  to  the 
action  of  the  flame,  as  when  a  woman’s  clothes  take  fire,  the  cutis  itself 
may  be  disorganized;  and  if  the  heat  be  still  more  intense,  as  when 
molten  metal  falls  upon  the  bod}',  the  soft  parts  may  be  deeply  charred, 
or  the  whole  thickness  of  a  limb  destroyed.  So,  also,  the  effects  of 
scalds  A'ary  greatly,  not  only  according  to  the  temperature  of  the  liquid, 
but  according  to  its  character;  the  more  oleaginous  and  thick  the  fluid, 
the  more  severe  usually  will  the  scald  be. 

These  various  results  of  the  application  of  heat  to  the  surface  have 
been  arranged  by  Dupuytren  into  six  different  degrees  of  burn.  This 
classification  is  not  merely  a  fanciful,  or  even  a  pathological,  arrange¬ 
ment  of  the  effects  produced  by  the  application  of  heat ;  but  it  is  of  great 
practical  importance,  as  the  degree  and  character  of  the  resulting  cica¬ 
trix  are  dependent  on  the  depth  to  which  the  burn  penetrates  into  the 
tissues.  Hence  these  future  conditions  can  be  determined  by  ascertain¬ 
ing,  in  the  first  instance,  the  degree  to  which  the  burn  belongs. 

In  the  first  degree^  the  application  of  fire  has  been  momentary.  It 
has  been  followed  by  congestive  redness  and  pain — phenomena  that 
resemble  erysipelas.  But  there  is  no  solution  of  continuity,  no  destruc¬ 
tion  of  tissue;  and  consequently  there  is  no  resulting  cicatrix.  This  is 
the  acute  stage  of  the  first  degree.  In  other  cases,  the  effects  may  be 
more  chronic,  as  in  those  instances  where,  in  old  people  who  sit  con¬ 
stantly  before  the  fire  or  over  charcoal  foot- warmers,  changes  are  gradu¬ 
ally  induced  in  the  integuments  and  superficial  structures  of  the  lower 
extremities. 

In  the  second  degree  the  cuticle  is  detached ;  and  there  are  vesications 
and  phlyctenm.  There  is  consequently  loss  of  substance,  so  far  as 
cuticle  is  concerned.  This  is  sometimes  followed  by  suppuration ;  and, 
although  no  cicatrix  results  in  these  cases,  yet  discoloration  of  the 
integument  is  often  left. 

In  the  third  degree  the  whole  of  the  cuticle  is  destroyed,  with  a  por¬ 
tion  of  the  true  skin;  but  the  cutis  vera  is  not  entirely  destroyed.  This 


LOCAL  EFFECTS  OF  BURNS. 


217 


is  a  most  important  point,  as  it  influences  materially  the  character  of  the 
resulting  cicatrix.  As  a  thin  laj'er  of  true  skin  is  left  at  the  bottom  of 
the  eschar,  complete  reproduction  of  the  whole  thickness  of  the  integu- 
mental  structures  is  not  necessary.  In  these  cases  there  is  a  vivid  red 
granulating  surface3  which  suppurates  abundantly.  As  the  action  of 
the  burn  extends  to  unequal  depths,  the  granulations  will  be  very 
irregular,  and,  unless  great  care  be  taken,  the  resulting  cicatrix  will  pre¬ 
sent  corresponding  elevations  and  depressions. 

In  the  fourth  degree  there  is  complete  destruction  of  the  skin  through 
its  whole  thickness,  so  that  it  is  perforated,  and  the  subcutaneous  areolar 
tissue  is  opened  up.  The  process  of  cicatrization  in  these  cases  may 
take  place  either  b}"  the  growing  together  of  the  opposite  sides  of  the 
wound  that  results  from  the  separation  of  the  eschars,  or  b3"  the  forma¬ 
tion  of  a  thick  and  highly’’  contractile  cicatrix  of  entirely  new  formation. 
The  process  of  repair  in  these  cases  is  veiy  slow,  and  is  attended  hy  long- 
continued  suppuration.  The  resulting  cicatrix  is  at  first  thin,  red  or 
purplish,  glazed,  often  in  the  form  of  bands  or  bridles,  and  is  liable  to 
occasion  great  deformity  by  the  cohesion  of  parts,  as  of  tlie  fingers,  or 
b}'  contraction,  as  at  the  elbow,  or  the  side  of  the  neck  and  face,  or  b}^ 
the  closure  of  apertures,  as  of  the  nostrils. 

In  the  fifth  and  sixth  degrees  the  destructive  influence  of  the  burn 
penetrates  to  a  greater  or  less  depth  into  the  muscles,  bones,  or  joints. 
Ill  the  fifth  degree,  the  more  superficial  muscular  structures  are  impli¬ 
cated  :  ill  the  sixth  degree  the  whole  thickness  of  the  limb  may  be 
destro^'ed  and  charred. 

This  is  very  briefly^  the  celebrated  classification  introduced  ly”  Dupu}’- 
tren,  and  adopted  by  most  writers  on  the  subject  as  a  practical  exposi¬ 
tion  of  the  local  effects  of  burns.  These  various  degrees  are  usually 
found  associated  to  a  greater  or  less  extent;  indeed,  in  the  more  severe 
cases,  the  first  three  or  four  degrees  are  almost  invariably'  met  with 
together. 

Surgically^,  the  fourth  degree  is  the  most  important,  and  most  severe 
burns  extend  to  it.  Its  importance  is  due  to  the  complete  destruction 
of  the  whole  thickness  of  the  skin,  and  the  consequent  extensive  granu¬ 
lating  and  suppurating  surfaces  that  are  left ;  and  the  tendency  to 
deformity'  from  the  contraction  of  the  cicatrices,  formed  as  they'  are  of 
entirely'  new  tissue,  the  great  jieculiarity'  and  tendency  of  which  is  to 
contract  into  hard  bands  and  bridles. 

The  primaiy  local  effect,  then,  of  a  burn,  if  superficial,  is  to  excite 
inflammation  of  the  skin  ;  if  more  extensive,  to  destroy'  more  or  less  the 
soft  structures,  and  even  the  bones.  'When  the  cuticle  is  unbroken,  the 
inflammation  speedily'  subsides  with  some  desquamation.  When  the  soft 
parts  are  charred,  they  are  detached  by'  a  process  of  ulceration,  analogous 
to  what  happens  in  the  separation  of  sloughs ;  and  an  ulcerating  and 
suppurating  surface  is  left,  remarkable  for  the  large  size,  the  florid  color, 
the  great  vascularity,  and  the  rapid  growth  of  its  granulations.  The 
cicatrization  of  such  an  ulcer,  though  generally  proceeding  with  great 
rapidity',  has  a  constant  tendency  to  be  arrested  by'  the  exuberance  of 
the  granulations.  The  cicatrix  is  usually'  thin,  and  of  a  bluish-red  color, 
and  is  especially' characterized  by' a  great  disposition  to  contract,  becom¬ 
ing,  after  a  time,  puckered  up,  and  much  indurated.  This  process  of 
contraction  and  hardening,  which  begins  immediately  on  the  completion 
of  cicatrization,  continues  for  many'  months,  giving  rise  frequently'  to  the 
most  distressing  deformities,  and  to  the  complete  loss  of  motion  and  use 
in  parts.  These  cicatrices  are  fibro-plastic  and  fatty',  and  often  extend 


218 


EFFECTS  OF  HEAT  AND  COLD. 


deeply  between  and  mat  together  the  muscles,  vessels,  and  soft  struc¬ 
tures  of  a  limb,  of  the  face,  or  of  the  neck. 

The  Constitutional  Effects  resulting  from  burn  are  most  serious 
and  important;  they  depend  not  so  much  upon  the  depth  of  the  injury 
as  upon  its  situation,  the  extent  of  surface  implicated,  and  the  age  of 
the  patient.  Thus  a  person  may  have  his  foot  completely  charred  and 
burned  off  b}"  a  stream  of  molten  iron  running  over  it,  with  far  less  con¬ 
stitutional  disturbance  and  danger  than  if  the  surface  of  the  trunk  and 
face  be  extensively  scorched  to  the  first  and  second  degrees  ;  burns  about 
the  chest,  the  head,  and  the  face,  being  far  more  likely  to  be  attended  by 
serious  constitutional  mischief  than  similar  injuries  of  the  extremities. 
In  children,  the  system  generally  suffers  more  severely  from  burns  than 
in  adults. 

The  constitutional  disturbance  induced  by  burns,  in  whatever  degree, 
ma}"  be  divided  into  three  stages:  1,  Depression  and  Congestion;  2, 
Reaction  and  Inflammation ;  3,  Suppuration  and  Exhaustion. 

1.  The  stage  of  Depression  of  the  Nervous  System  and  Congestion  of 
Internal  Organs^  occupies  the  first  fortj'-eight  hours ;  during  which 
death  may  occur  before  inflammatory  action  can  come  on.  Immediately 
on  the  receipt  of  a  severe  burn  the  patient  becomes  cold  and  collapsed, 
and  is  seized  with  fits  of  shivering,  which  continue  for  a  considerable 
time.  He  is  evidently  suffering  from  the  shock  of  the  injury  ;  the 
severit}"  of  the  shivering  is  usuall}'  indicative  of  the  extent  of  the  con¬ 
stitutional  disturbance,  and  is  more  prolonged  in  those  injuries  that 
occupy  a  great  extent  of  surface,  even  though  it  be  only  burnt  to  the 
first  or  second  degree,  than  in  those  which,  being  of  more  limited  super¬ 
ficial  extent,  affect  the  tissues  deeply.  On  the  subsidence  of  the  symp¬ 
toms  of  depression,  there  is  usually  a  period  of  quiescence  before  reaction 
comes  on;  and  during  this  period  the  patient,  especially  if  a  child,  not 
unfrequentlj'  dies  comatose;  death  resulting  from  congestion  of  the 
brain  and  its  membranes,  with,  perhaps,  serous  effusion  into  the  ven¬ 
tricles  or  the  arachnoid.  Besides  these  lesions,  the  mucous  membrane 
of  tlie  stomach  and  intestines,  as  well  as  the  substance  of  the  lungs,  is 
usLiall}^  found  congested. 

The  pathological  phenomena  of  this  period  are  altogether  of  a  conges¬ 
tive  character.  Of  15  cases  in  which  the  contents  of  the  cranium  were 
examined,  I  found  congestion  of  the  brain  and  its  membranes,  with  serous 
effusion,  in  all;  in  II  of  these  cases  the  thoracic  viscera  were  found  to 
be  congested  in  9,  healthy  in  5 ;  and  of  14  in  whicli  the  abdominal  organs 
were  examined,  congestion  of  the  gastro-intestinal  mucous  membrane 
was  found  in  12  cases,  and  a  health}^  condition  in  2  only. 

2.  The  next  stage,  that  of  Reaction  and  In  flammation^  extends  from 
the  second  da}’’  to  the  second  week.  In  it  irritative  fever  sets  in  earljq 
witli  a  degree  of  severity  proportionate  to  the  previous  depression  ;  and, 
as  this  stage  advances,  it  is  attended  by  special  symptoms,  dependent 
upon  inflammatory  affections,  more  especiall}'^  of  the  abdominal  and 
thoracic  viscera.  Death,  w'hich  is  more  frequent  during  this  stage  than 
in  the  preceding  one,  is  usually  connected  with  some  inflammatory  con¬ 
dition  of  the  gastro-intestinal  mucous  membrane,  or  of  the  peritoneum. 
The  lungs  also  are  frequently  affected,  showing  marked  evidence  of  pneu¬ 
monia  or  bronchitis;  but  the  cerebral  lesions  are  not  so  common  as  in 
the  first  stage;  though,  when  they  occur,  they  present  more  unequivocal 
evidence  of  inflammatory  action.  The  following  are  the  results  of  the 
post-mortem  examinations  which  I  have  made.  Of  17  cases  in  which 


PROGNOSIS  OF  BURNS. 


219 


the  contents  of  the  cranium  were  examined  during  this  period,  there  was 
congestion,  'with  evidence  of  inflammation  and  effusion  of  serous  fluid, 
usually  with  blood,  in  14;  a  health}"  state  in  the  remaining  3.  Of  19 
cases  in  which  the  lungs  were  examined,  there  was  congestion  of  these 
organs,  probably  inflammatory  in  most  instances  ;  with  serum  or  lymph 
in  the-  pleura,  and  redness  of  the  bronchial  mucous  membrane,  in  10. 
The  lungs  were  hepatized  in  5,  and  healthy  in  4.  The  abdominal  organs 
were  examined  in  22  cases;  of  these  there  was  congestion  of  the  mucous 
membrane,  sometimes  with  evidence  of  peritonitis,  in  11 ;  ulceration  of 
the  duodenum  in  6;  a  healthy  state  in  5. 

It  is  in  this  stage  of  burn,  that  the  veiy  remarkable  and  serious  sequela, 
perforating  ulcer  of  the  duodenum^  is  especially  apt  to  occur.  Curling, 
who  first  attracted  attention  to  it,  explained  its  occurrence  b}"  the  suppo¬ 
sition  that  Briinner’s  glands  endeavor  by  an  increased  action  to  compen¬ 
sate  for  the  suppression  of  the  exhalation  of  the  skin  consequent  upon 
the  burn;  and  that  the  irritation  thus  induced  tends  to  their  inflammation 
and  ulceration.  This  ulceration  may,  as  Curling  remarks,  by  rapidly 
proceeding  to  perforation,  expose  the  pancreas,  open  the  branches  of 
the  hepatic  arteiy,  or,  by  making  a  communication  with  the  serous 
cavity  of  the  abdomen,  produce  peritonitis,  and  thus  cause  death.  It 
usuall}"  comes  on  about  the  tenth  day  after  the  occurrence  of  the  injury; 
seldom  earlier  than  this.  The  only  exception  with  which  I  am  acquainted 
was  in  the  case  of  a  child  nine  3"ears  of  age,  who  died  on  the  fourth  day 
after  the  burn,  in  University  College  Hospital,  and  in  whom  an  ulcer, 
of  about  the  size  of  a  shilling,  with  sharp  cut  margins,  was  found  in  the 
duodenum;  the  intestinal  mucous  membrane  generally  being  inflamed. 
That  these  ulcers  are  not  invariabl}"  fatal,  is  evident  from  a  case  men¬ 
tioned  by  Curling,  in  which,  on  death  occurring,  from  other  causes,  eight 
weeks  after  the  injury,  a  recent  cicatrix  was  found  in  the  duodenum. 
These  affections  seldom  occasion  any  very  marked  symptoms  to  indicate 
the  nature  of  the  mischief,  the  patient  suddenly  sinking.  In  some 
instances  there  is  hemorrhage  ;  though  this  is  not  an  unequivocal  sign, 
as  I  have  several  times  seen  it  happen  from  simple  inflammatory  conges¬ 
tion  of  the  intestinal  mucous  membrane.  Pain  in  the  right  hj'pochondriac 
region,  and  perhaps  vomiting,  may  also  occur. 

3.  The  stage  of  Sujjpuration  and  Exhaustion  continues  from  the 
second  week  to  the  close  of  the  case.  In  it  we  frequently  have  sj^mp- 
toms  of  hectic,  with  much  constitutional  irritation  from  the  long  con¬ 
tinuance  of  exhausting  discharges.  If  death  occur,  it  is  most  frequently 
induced  by  inflammation  of  the  lungs  or  pleura;  affections  of  the  abdom¬ 
inal  organs  and  brain  being  rare  during  this  stage  of  the  iujuiy. 

Of  7  cases  in  which  the  lungs  were  examined,  they  were  found  to  be 
^  healthy  in  1  only;  being  hepatized,  with  effusion  in  the  pleurm,  in  the 
remaining  6  cases.  Of  7  cases  in  which  the  abdominal  organs  were 
examined,  a  healthy  state  was  found  in  4  ;  inflammatoiy  congestion  in  2; 
and  a  cicatrized  ulcer  in  the  stomach  in  1.  Of  5  of  the  cases  the  cerebral 
contents  were  found  healthy  in  I  only;  there  being  inflammatoiy  con¬ 
gestion  in  the  other  4. 

Prognosis. — The  influence  of  extent,  degree,  and  situation,  on  the 
prognosis  of  burns  has  already  been  stated.  The  most  fatal  element 
indeed  of  these  injuries  is  superficial  extent.  Xot  only  do  the  cutaneous 
nerves  become  greatly  irritated,  and  the  nervous  S3"stem  generalh"  suffer 
severel}",  from  the  shock  of  an  extensive  burn ;  but,  the  cutaneous  secre¬ 
tion  being  arrested  over  a  large  surface  of  the  skin,  congestion  of  the 


220 


EFFECTS  OF  HEAT  AND  COLD. 


internal  organs  and  of  the  mucous  membrane  must  ensue;  and  hence 
death  may  happen  directly  from  this  cause,  or  from  the  supervention  of 
inflammation  in  the  already  congested  parts;  more  particularly  in  the 
early  periods  of  life,  when  the  balance  of  the  circulation  is  readily  dis¬ 
turbed.  The  degree  of  burn  influences  the  prognosis  unfavorably  rather 
so  far  as  the  part  itself  is  concerned,  than  as  the  general  system  is 
affected.  The  most  fatal  pei'iod  in  cases  of  burn  is  the  first  week  after 
the  accident.  I  find  that,  in  50  cases  of  death  from  these  accidents,  33 
proved  flital  before  the  eighth  day ;  27  of  these  dying  before  the  fourth 
day.  Of  the  remaining  17  cases,  8  died  in  the  second  week,  2  in  the 
third,  2  in  the  fourth,  4  in  the  fifth,  and  1  in  the  sixth. 

Mode  of  Death  from  Burn. — When  in  an  ordinary  conflagration 
a  person  is  ‘‘burnt  to  death,”  the  fatal  event  is  occasioned  not  by  the 
charring,  roasting,  or  actual  burning  of  the  body,  but  by  the  induction 
of  asphyxia.  Life  is  mercifully  extinguished  by  suffocation  in  the  smoke, 
gases,  and  noxious  vapors  resulting  from  the  fire,  before  the  body  itself 
is  consumed. 

When  a  person  is  severely  and  extensively  burnt,  and  dies  in  the 
course  of  a  few  hours,  or  a  day  or  two,  death  arises  usually  from  shock, 
which  is  most  severe  and  continuous.  Dupuytren  was  of  opinion  that 
during  this  stage  the  sufferer  died  from  the  excessive  pain,  and  stated 
that  “  too  great  a  loss  of  sensibility  might  kill  as  well  as  too  great  a  loss 
of  blood.”  Whether  this  be  so  or  not,  it  is  perhaps  difficult  to  say; 
but  the  fact  remains  certain  that,  in  individuals  who  die  during  this 
stage,  the  brain  and  its  membranes  will  invariably  be  found  congested, 
usually  with  more  or  less  effusion  of  serous  fluid  into  the  ventricles  of 
the  arachnoid.  This  I  have  invariably  found  in  every  case  that  I  have 
examined.  In  one-half  of  the  cases  I  have  found  congestion  of  the  tho¬ 
racic  organs,  and  in  the  majority  congestion  of  the  abdominal  organs, 
more  especially  of  the  mucous  membrane  of  the  stomach  and  ileum.  Death 
during  the  second  stage  is  usually  dependent  upon  internal  inflammation, 
more  particularly  of  the  gastro-intestinal  mucous  membrane  and  lungs, 
and  less  frequently  of  the  brain  and  its  membranes.  If  the  patient 
survive  into  the  period  of  suppuration,  and  then  succumb,  he  will  usually 
die  from  exhaustion,  hastened  or  accompanied  by  inflammation  of  the 
lungs  or  pleura. 

Treatment. — The  treatment  of  burns  must  have  reference  to  the 
constitutional  condition,  as  well  as  to  the  local  injury.  A  vast  variety 
of  local  applications  have  been  recommended  by  different  Surgeons,  such 
as  flour,  starch,  cotton-wadding,  treacle,  white  paint,  gum,  solution  of 
India-rubber,  etc.;  the  principle  of  all  these  applications  is,  however,  the 
same,  viz.,  the  protection  of  the  burnt  surface  from  the  air.  I  shall  here 
content  myself  with  describing  the  method  that  is  usually  followed  with 
much  success  at  the  University  College  Hospital. 

The  Constitutional  Treatment  is  of  the  utmost  consequence.  We 
have  seen  how  death  arises  in  various  periods  after  these  accidents  from 
different  causes,  and  we  must  modify  our  treatment  accordingly.  The 
first  thins  to  be  done  after  the  infliction  of  a  severe  burn  is  to  bring 
aVjout  reaction  ;  the  patient  is  trembling  in  a  state  of  extreme  depression, 
suffering  great  pain,  is  cold  and  shivering,  and  may  sink  from  the  shock 
unless  properly  supported.  A  full  dose,  varied  according  to  the  age,  of 
liquor  opii,  should  be  given  at  once  in  some  warm  brandy-and-water,  and 
repeated,  if  necessary,  in  the  course  of  an  hour  or  two. 

When  reaction  has  fairly  set  in,  the  patient’s  secretions  should  be  kept 


TREATMENT  OF  BURNS  AND  SCALDS. 


221 


free  by  the  administration  of  an  occasional  mild  purgative  and  salines. 
Should  any  inflammatory  symptoms  about  the  head,  chest,  or  abdomen 
manifest  themselves,  it  will  be  necessary  to  have  recourse  to  treatment 
proportionate  to  their  nature.  I  have  certainl}^  seen  patients  saved  in 
these  circumstances  by  the  employment  of  blood-letting  and  the  appli¬ 
cation  of  leeches.  But,  in  the  vast  majority  of  instances,  the  visceral 
complications  are  low  and  congestive.  In  such  cases  our  great  reliance 
must  be  on  stimulants.  Ammonia  and  bark,  brandy  and  wine,  require 
to  be  freel3’ given,  with  a  sufiicienc3' of  nourishment ;  and  the  irritabilit3’’ 
of  the  nervous  S3'stem  must  be  soothed  b3"  the  frequent  administration 
of  full  doses  of  opium.  At  a  later  period,  when  the  strength  has  become 
weakened  by  the  profuseness  of  the  discharges,  this  tonic  and  stimula¬ 
ting  plan  must  be  activel3’  continued. 

Local  Treatment. — The  burnt  clothes  having  been  removed,  the  patient 
should  be  laid  upon  a  blanket,  and,  whatever  the  degree  of  the  burn,  be 
well  covered  with  the  finest  wheaten  flour  by  means  of  an  ordinary 
dredger.  The  flour  should  be  laid  on  thickl3’,  but  uniformly  and  gradu- 
all3’ ;  it  forms  a  soft  and  soothing  application  to  the  surface.  If  the 
cuticle  have  been  abraded  or  vesicated,  the  flour  will  form  a  thick  crust, 
b3"  admixture  with  the  serum  discharged  from  the  broken  surface.  If 
the  skin  be  charred,  the  discharge,  which  will  be  speedily  set  up  around 
the  eschar,  will  make  the  flour  adhere  to  the  part,  forming,  as  it  were,  a 
coating  impervious  to  the  air.  The  crusts  thus  formed  should  not  be 
disturbed  until  the)^  become  loosened  b3^  the  influence  of  the  discharges, 
when  the3' should  be  removed;  and  the  ulcerated  surface  that  is  exposed 
should  be  dressed  with  water-dressing,  red-wash,  or  lead  ointment, 
according  to  the  amount  of  irritation  existing,  the  suppurating  sore 
indeed  being  managed  on  ordinal^  i)rinciples.  In  some  cases,  lint  dipped 
in  the  “  Carron  composed  of  equal  parts  of  linseed  oil  and  lime- 
water,  to  which  a  small  quantity  of  spirits  of  turpentine  might  be  added, 


Fig.  81. 


Fig.  82. 


Contraction  of  Elbow  from  Cicatrix  of  Burn  of 
Fourth  Degree. 


Contraction  of  Thumb  from  Burn  of 
Fourth  Degree. 


has  appeared  to  agree  better  than  an3Thing  else :  and  in  others  cotton¬ 
wadding  answers  admirabl3\  Whatever  local  application  be  adopted,  I 
hold  it  to  be  of  the  utmost  importance  in  the  earl3'  stages  of  the  burn  to 


222 


EFFECTS  OF  .HEAT  AND  COLD. 


change  the  dressings  as  seldom  as  possible;  not,  indeed,  until  they  have 
been  loosened,  or  rendered  offensive  by  the  imbibition  of  the  discharges. 
Every  fresh  dressing  causes  the  patient  very  severe  pain,  produces 
depression,  and  certainly  retards  materially  the  progress  of  the  case. 

Prevention  and  Removal  of  Contraction. — As  cicatrization 
advances,  the  exuberant  growth  of  granulations  should  be  carefully 
repressed  by  the  free  use  of  nitrate  of  silver;  and  the  part  must  be 
fixed  in  a  proper  position  by  means  of  bandages,  splints,  and  mechanical 
contrivances,  specially  adapted  to  counteract  the  tendency  to  contraction 
of  the  cicatrix,  and  consequent  deformity.  This  is  especially  necessary 
in  burns  about  the  neck,  where  the  chin  is  liable  to  be  drawn  down  on 
the  sternum  ;  and  in  burns  at  the  inside  of  limbs  or  the  flexures  of  joints, 

more  especiall}^  the  elbow,  where  contraction 
is  yevy  apt  to  ensue.  (Fig.  81.)  In  bad 
burns  of  the  hands,  the  fingers  may  be 
drawn  into  and  fixed  upon  the  palm  of  the 
hand,  may  become  webbed  together,  or  may 
be  dislocated  and  fixed  immovably  against 
the  dorsum.  The  accompanying  w^oodcuts 
are  good  illustrations  of  the  bad  effects  of 
burns  upon  the  hands.  In  Fig.  83  the  little 
finger  has  been  dislocated  backwards,  and 
fixed  upon  the  dorsum.  In  Figs.  84  and 
85,  the  two  hands  were  frightfully  deformed 
— the  fingers  being  partly  consumed,  and 
partly  webbed  and  matted  together  by  dense  cicatricial  tissues.  This 
accident  occurred  in  consequence  of  the  night-shirt  taking  fire.  The 


Fig.  83. 


Dislocation  backwards  of  Little  Finger 
from  Contraction  of  Ibe  Cicatrix  of  a 
Burn  of  the  Fourth  Degree. 


Fig.  84. 


Deformity  of  Eight  Hand  from  Burn  of  the  Fourth 
or  Fifth  Degree. 


Fio;.  85. 


Deformity  of  Left  Hand  from  Burn  of  the 
Fifth  Degree. 


patient  tried  to  extricate  himself  by  drawing  the  burning  garment  over 
his  head,  but,  the  wristbands  being  buttoned,  he  could  not  withdraw  the 
hands,  which  were  frightfully  burnt.  Fig.  82  represents  the  thumb  drawn 
into  such  a  position  as  to  be  no  longer  capable  of  being  brought  into 
opposition  to  the  fingers.  In  the  early  treatment  of  such  cases,  I  have 
advantageous!}^  employed  the  elastic  traction  of  India-rubber  bands  to 
counteract  the  tendency  to  contraction  of  the  scar. 

Similar  contractions  may  occur  in  the  foot,  leaving  great  deformit^q 
as  in  Fig.  86,  where  the  heel  is  shown  to  be  retracted,  and  the  whole  of 
the  toes  spread  out  in  a  fan  shape.  In  this  case  amputation  (Pirogoff ’s) 
was  the  only  means  left  for  securing  an  useful  limb. 

The  contracted  cicatrices  resulting  from  burns  may,  if  of  recent  date, 
be  extended  or  stretched  out  by  the  pressure  of  strips  of  plaster,  or  the 


OPERATIONS  ON  CONTRACTED  CICATRICES. 


22B 


Fig.  86. 


Deformed  Foot 
from  Burn  of  the 
Fourth  and  Fifth 
Degrees. 


action  of  rack-and-pinion  apparatus.  The  good  effect  of  this  plan  of 
treatment  is  especially  marked  in  contractions  at  the  elbow,  or  in  those 
that  fix  the  arm  to  the  side.  These  means  are  particular¬ 
ly  useful  in  children,  and  indeed  are  so  in  all  cases,  pro¬ 
vided  the  cicatrix  be  not  too  old — not  more  than  a  year; 
after  that  time,  it  will  seldom  yield  without  division. 

Operations  for  the  Removal  of  the  Effects  of  Contrac¬ 
tion  consequent  upon  burns  are  occasionally  required; 
and,  if  judiciously  planned  and  executed,  may  do  much 
to  remedy  the  patient’s  condition.  The  operations  tliat 
are  practised  with  this  view  are  of  two  kinds.  1.  Simple 
Division  of  the  Faulty  and  Contracted  Cicatrix;  2.  The 
Transplantation  of  a  Flap  of  adjacent  healthy  Skin  into 
the  gap  left  after  the  division  of  the  cicatrix. 

1.  In  the  first  operation,  that  of  simply  Dividing  the 
Cicatrix^  three  points  require  special  attention :  1st,  that 
the  division  extend  completely  through  the  cicatrix  from 
side  to  side  into  the  adjacent  healthy  skin ;  2d,  that  the 
incision  be  carried  through  the  whole  depth  and  thick¬ 
ness  of  the  cicatrix  into  the  healthy  cellulo-adipose  la^^er 
which  will  be  found  beneath  it,  and  may  alwaj^s  be  re¬ 
cognized  by  its  yellow  color ;  3d,  that  all  contractile 

bands  lying  in  this  la3'er  be  fairly  divided.  The  great  obstacle  to 
the  success  of  this  operation,  however,  consists  in  the  fact  that  the  new 
granulations,  which  spring  up  after  the  division  of  the  contracted  cica¬ 
trix,  are  in  their  turn  liable  to  take  on  contractile  action.  After  the 
division  of  the  cicatrix,  also,  it  may  be  found  that  the  subjacent  struc¬ 
tures  have  been  so  rigidly' fixed  in  their  abnormal  position  as  not  to 
admit  of  extension.  It  ma^"  then  be  necessary  to  employ  screw-appa¬ 
ratus,  or  even  to  divide  fasciae  and  tendons,  before  the  part  can  be 
restored  to  its  normal  shape.  Care  must,  however,  be  taken  in  doing 
this,  that  subjacent  structures  of  importance,  such  as  large  bloodvessels, 
or  nerves,  be  not  so  closely  connected  with  the  cicatrix  as  to  render 
wound  or  division  of  them  unavoidable.  In  the  neck,  cicatricial  bands 
will  often  come  into  very  dangerous  proximitj^  to  the  external  jugular 
vein,  which  becomes  greatly  distended  b}^  the  pressure  thus  exercised 
upon  it.  And  at  the  elbow,  which  is  a  common  seat  of  contraction  from 
burns,  the  brachial  artery  may  become  involved  in  the  cicatrix  to  a 
dangerous  extent.  I  have  heard  of  one  case  in  which  this  vessel  was 
divided  in  cutting  through  the  cicatrix,  when  amputation  of  the  arm  was 
immediately  resorted  to. 

These  operations  are  most  likely  to  be  successful  in  cases  of  contrac¬ 
tion  at  the  flexures  of  the  joints,  as  of  the  elbow.  There,  all  that  need 
be  done  is  to  divide  the  cicatrix  down  to  the  subjacent  healthy  struc¬ 
tures,  and  then,  b}’-  the  proper  application  of  splints  or  screw-apparatus, 
gradually  to  extend  the  limb,  and  allow  granulation  to  go  on  in  the 
extended  position.  Much  caution,  however,  will  here  be  necessary;  for, 
if  the  contraction  be  of  A^ery  old  standing,  the  arteries  and  nerves  will 
have  become  shortened,  and  incapable  of  stretching  under  any  force 
that  ma^^  be  safely  employed  ;  hence  they  may  easily  be  torn. 

2.  Operations  that  are  undertaken  for  the  removal  of  the  disfigure¬ 
ments  that  occur  about  the  face  and  neck  as  the  result  of  burns,  require 
much  management.  In  these  cases  simple  division  of  the  cicatrix  is 
insufficient ;  and  Transplantation  of  a  Flap  of  Skin  is  required  in 
addition.  After  the  cicatrix  and  all  cicatricial  bands  have  been  freely 


224 


EFFECTS  OF  HEAT  AND  COLD. 


divided  in  accordance  with  the  rules  just  given,  a  flap  of  iutegumeutal 
structure,  of  sufficient  size  to  fill  the  greater  part  of  the  gap,  must  be 
dissected  up  from  the  neighboring  parts  of  the  neck,  chest,  or  shoulder, 
and  laid  into  the  cicatrix.  There  it  should  be  fixed  by  two  or  three 
points  of  suture ;  but  extreme  care  must  be  taken  that  no  traction 
be  put  upon  it,  lest  it  slough.  Union  takes  place  by  the  second  inten-* 
tion  in  the  majority  of  instances;  but  a  very  satisfactory  resuir is  left, 
as  is  shown  by  the  annexed  figures  (87,  88),  taken  before  and  after  opera- 


Fig.  87. 


Fig.  88. 


Cicatrix  of  Lip  and  Xeck  before  Operation. 


The  same  Patient  after  Operation. 


tion,  and  as  has  been  illustrated  in  many  cases  by  Mutter  and  Teale, 
who  have  particularly  distinguished  themselves  in  such  operations.  The 
directions  given  by  Teale  for  the  restoration  of  the  lower  lip  when 
dragged  down,  eA^erted,  and  partially  destroyed,  by  cicatrization  follow¬ 
ing  burn,  are  so  simple  and  lead  to  such  excellent  results,  that  I  giA^e 
them  nearly  in  his  own  words.  The  CA^erted  lip  is  divided  into  three 
i:)arts,  b3'  two  A'ertical  incisions  three-quarters  of  an  inch  long,  carried 
down  to  the  bone.  These  incisions  are  so  planned  that  the  middle 
portion  between  them  (Fig.  89,  B)  occupies  one-half  of  the  lip.  From 


Fig.  89. 


Incisions  in  Teale's  Operation  for  Cica¬ 
tricial  Deformity  of  the  Lower  Lip. 


Fig.  90. 


Teale’s  Operation  :  the  Flaps  in  Place. 


the  lower  end  of  each  incision  the  knife  is  carried  upwards  to  a  point 
one  inch  be^'Ond  the  angle  of  the  mouth  (A).  The  two  flaps  thus 
marked  out  are  freeh"  and  deeply  dissected  up.  Tfie  alATolar  border  of 
the  middle  portion  is  then  freshened.  The  lateral  flaps  (Fig.  90,  C  A) 


WARTY  CICATRICES. 


225 


are  now  raised,  united  by  twisted  sutures  in  the  mesial  line,  and  sup¬ 
ported  as  on  a  base  by  the  middle  flap,  to  which  they  are  also  attached 
by  a  few  points  of  suture,  leaving  a  triangular  even  surface  (CC)  to  gran¬ 
ulate.  In  addition  to  the  division  of  the  cicatrix,  James,  of  Exeter,  in 
these  cases  very  successfully  employed  a  screw-collar,  by  which  the 
chin  can  be  loosened  from  the  sternum,  and  gradual  extension  of  the 
cicatrix  effected. 

In  severe  burns  of  the  side  of  the  face  and  neck  the  resulting  cicatrix 
is  sometimes  so  dense,  resisting,  and  contracted,  that  immobilit}^  of  the 
jaw  results  and  the  mouth  cannot  be  opened,  or  at  most  the  teeth  can 
only  be  separated  to  a  slight  extent,  so  as  to  admit  liquid  nourishment. 
In  ord^r  to  restore  the  mobility  of  the  jaw  and  the  power  of  separating 
the  teeth  in  these  cases,  Rizzoli  and  Esmarch  have  proposed  making  a 
false  joint  in  the  lower  jaw  on  the  side  burnt,  immediately  in  front  of 
the  cicatrix.  Rizzoli  does  this  by  simple  division  of  the  bone  by 
means  of  a  narrow  saw  :  Esmarch  recommends,  as  a  more  effectual 
procedure,  the  removal  of  a  wedge-shaped  piece  of  bone  about  three- 
quarters  of  an  inch  in  width  above  and  one  inch  in  width  below.  After 
this  has  been  done,  the  patient  will  be  able  to  move  the  jaw  at  the 
normal  articulation  on  the  healthy  side  and  at  the  false  joint  where  the 
jaw  has  been  cut  across. 

Warty  Cicatrices. — The  cicatrices  of  burns,  especially  on  the  neck 
and  chest,  occasionally  assume  after  a  time  a  projecting,  red,  and  glazed 
appearance,  as  if  they  were  composed  of  a  mass  of  fungating  granula¬ 
tions,  smoothed  down  and  lightly  skinned  over.  This  condition,  which 
may  be  looked  on  as  a  substantive  disease,  and  resembles  cheloid  in 
appearance,  has  chieflj’  been  met  with  in  children ;  but  I  have  several 
times  seen  it  in  the  adult,  in  women  who  had  been  badly  burnt  by  their 
dresses  taking  fire.  In  these  cases  I  observed  what  I  have  noted  in 
other  similar  instances  in  children ;  that  the  warty  cicatrices  were  the 
seat  of  the  most  intolerable  itching,  which  no  external  application 
seemed  to  relieve.  I  have,  however,  seen  the  pruritus  mitigated  by 
the  administration  of  large  doses  of  liquor  potassse.  If  small  and  nar¬ 
row,  these  cicatrices  ma}’^  be  dissected  out :  if  large,  they  cannot  be 
removed  without  risk  of  much  hemorrhage,  as,  though  fibroid,  they  are 
very  vascular. 

The  cause  of  this  peculiar  outgrowth  of  dense  cicatricial  tissue  is 
altogether  unknown.  It  may  in  some  cases,  perhaps,  be  owing  to  want 
of  care  in  checking  the  luxuriance  of  the  granulations ;  but  in  other 
cases  it  occurs  though  every  attention  is  paid  to  the  healing  of  the 
wound. 

The  cicatrix  of  a  burn  may  undergo  malignant  degeneration  many 
years  after  its  formation.  I  have  removed  a  large  cancroid  growth  from 
the  cicatrix  of  a  burn,  on  the  forearm  of  a  woman,  seventy  years  after 
the  injury  had  been  inflicted,  which  happened  when  she  was  between 
three  and  four  years  of  age. 

Amputation  may  be  required  if  the  burn  have  destroyed  the  whole 
thickness  of  a  limb ;  the  part  charred  should  then  be  removed  at  once, 
at  the  most  convenient  point  above  the  seat  of  injury.  This  operation 
may  also  be  required  at  a  later  period,  if,  on  the  separation  of  the 
eschars,  it  be  found  that  a  large  joint  has  been  opened,  and  is  suppu¬ 
rating  ;  or  if  the  disorganization  of  the  limb  be  so  great  as  to  exhaust 
the  powers  of  the  patient  in  the  efforts  at  repair.  Great  caution,  how¬ 
ever,  should  be  emplo3"ed  in  determining  on  the  propriety  of  amputating 
when  the  burn  has  extended,  though  in  a  minor  degree,  to  other  parts 
VOL.  I. — 15 


226 


EFFECTS  OF  HEAT  AND  COLD. 


of  the  bod}’,  lest  the  powers  of  the  patient  be  insufficient  for  the  double 
call  that  will  thus  be  made  upon  them. 

FROSTBITE. 

When  the  body  has  been  exposed  to  severe  or  long-continued  cold, 
we  find,  as  in  the  case  of  burns,  that  local  and  constitutional  effects  are 
produced. 

Local  Influence  of  Cold. — This  is  chiefly  manifested  on  the  extre¬ 
mities  of  the  body,  as  the  nose,  ears,  chin,  hands,  and  feet,  where  the 
circulation  is  less  active  than  at  the  more  central  parts.  It  chiefly  occurs 
to  an  injurious  degree  in  very  young  or  aged  persons,  or  in  those  whose 
constitutions  have  been  depressed  by  want  of  the  necessaries  of  life. 
In  such  persons  frostbite  and  the  resulting  gangrene  are  less  due  to  the 
low  temperature  to  which  they  are  exposed,  than  to  the  habitual  low 
vitality  of  the  extremities. 

In  the  first  degree  of  frostbite  that  calls  for  the  attention  of  the  Sur¬ 
geon  there  is  a  feeling  of  stiffness,  with  complete  numbness  of  the  part 
that  has  been  exposed  to  cold  ;  it  is  pale,  with  a  bluish  tint,  and  some¬ 
what  shrunken.  In  this  state  the  vitality  of  the  part  is  not  destroyed, 
but  merely  suspended.  On  the  return  of  circulation  in  the  affected  part, 
a  burning  tingling  pain  is  felt,  it  becomes  red,  and  shows  signs  of  a  ten¬ 
dency  to  inflammatory  action.  Indeed,  this  appearance  of  inflammation, 
often  accompanied  by  a  burning  sensation,  is  probably  the  immediate 
consequence  of  extreme  degrees  of  cold,  as  it  is  experienced  on  touching 
solidified  carbonic  acid  or  frozen  mercury. 

In  the  next  degree,  the  vitality  of  the  part  is  completely  destroyed ; 
all  sensibility  and  motion  in  it  are  lost,  it  becomes  shrunken  and  livid  ; 
but  though  its  vitality  may  have  been  annihilated  by  the  immediate 
application  of  the  cold,  it  is  not  until  the  part  has  become  thawed  that 
gangrene  usually  manifests  itself;  it  then  appears  to  do  so  by  the  vio¬ 
lence  of  the  reaction  induced,  the  part  rapidly  assuming  a  black  color, 
becoming  dry,  and  separating  eventually,  as  all  other  mortified  parts  do, 
by  the  formation  of  a  line  of  ulceration  around  it. 

The  Constitutional  Effects  of  a  low  temperature  need  not  detain  us. 
It  is  well  known  that,  after  exposure  to  severe  or  long-continued  cold,  a 
feeling  of  heaviness  and  stupor  comes  on,  and  gradually  creeps  on  to  an 
overpowering  tendency  to  sleep,  which,  if  yielded  to,  terminates  in  coma, 
and  a  speedy,  though  probably  painless,  death. 

Treatment  of  Frostbite. — This  consists  in  endeavoring  to  restore 
the  vitality  of  the  frozen  parts.  In  doing  this  the  great  danger  is,  that 
reaction  may  run  on  to  so  great  a  degree  as  to  induce  sloughing  of  the 
structures,  the  vitality  of  which  has  already  been  seriously  impaired. 
In  order  to  prevent  this  accident,  the  temperature  must  be  elevated  very 
gradually  and  with  extreme  care.  The  patient  should  be  placed  in  a 
cold  room,  without  a  fire,  any  approach  to  which  would  certainly  lead 
to  tlie  destruction  of  the  frostbitten  members.  These  must  then  be 
gently  rubbed  with  snow,  or  cloths  dipped  in  cold  water,  and  held 
between  the  hands  of  the  person  manipulating  ;  as  reaction  comes  on, 
they  may  be  enveloped  in  flannel  or  woollens,  and  a  small  quantity  of 
some  warm  liquid  or  s^jirit  and  water  may  be  administered.  In  this 
way  sensibility  and  motion  will  be  gradually  restored,  often  with  much 
burning  and  stinging  j^ain,  redness,  and  vesication  of  the  part.  If  gan¬ 
grene  have  come  on,  or  if  the  reaction  run  into  sloughing,  the  sphace¬ 
lated  part,  if  of  small  size,  should  be  allowed  to  detach  itself  by  the 


INJURIES  OF  BLOODVESSELS. 


227 


natural  process  of  separation,  which  should  be  as  little  interfered  with 
as  possible,  the  vitality  of  the  parts  continuing  at  a  low  ebb,  and  exten¬ 
sion  of  gangrene  being  readily  induced.  If  the  gangrened  parts  be  of 
greater  magnitude,  amputation  may  be  required.  This  should  be  done 
at  the  most  convenient  situation,  as  soon  as  the  line  of  separation  has 
fully  formed. 

If  the  person  who  has  been  exposed  to  cold  be  apparently  dead,  he 
must  be  put  in  a  cold  room,  the  temperature  of  which  must  be  very 
slowly  raised.  Friction,  as  just  described,  should  be  practised,  and 
artificial  respiration  set  up.  These  means  must  be  continued  for  a  long 
time,  even  if  no  signs  of  life  appear:  there  being  on  record  instances  of 
recovery  after  several  hours  of  suspended  animation. 


CHAPTER  XIII. 

INJURIES  OF  BLOODVESSELS. 

INJURIES  OF  VEINS. 

Veins  are  very  commonly  wounded  suicidall}’,  accidentally,  or  in 
surgical  operations;  but,  unless  they  be  deeplj^  seated,  their  injuries 
are  seldom  attended  by  any  serious  consequences.  Occasionally  sub¬ 
cutaneous  rupture  or  laceration  of  a  vein  takes  place  from  a  blow  or 
strain.  In  such  cases  extensive  extravasation  of  blood  will  occur,  which, 
however,  usually  undergoes  absorption  in  a  few  weeks ;  but  it  may  sup¬ 
purate,  or  take  on  itself  the  changes  described  at  page  165.  This 
accident  is  most  commonly  seen  in  the  saphena  vein. 

There  are  three  sources  of  danger  in  open  wounds  of  veins  :  1,  Loss 
of  Blood  ;  2,  Diffuse  Inflammation  of  the  Vessel ;  3,  Entrance  of  Air  into 
the  Circulation. 

1.  A  vein  is  known  to  be  wounded,  when  dark  blood  flows  in  a  rapid 
and  uniform  stream  from  the  seat  of  injuiy.  If  the  vessel  wounded  be 
one  of  considerable  magnitude,  or  in  close  proximity'  to  the  centre  of  the 
circulation,  the  flow  of  blood  ma}"  be  rapidly  fatal,  more  especially  if  its 
escape  be  favored  by  the  dependent  position  of  the  part. 

The  Hemorrhage  from  a  wounded  vein  maj^,  if  the  vessel  be  superficial, 
be  arrested  bj"  position, -and  the  pressure  of  a  compress,  with  a  few  turns 
of  a  roller.  If  the  vein  be  one  of  considerable  size,  as  the  internal 
jugular,  or  if  it  be  so  situated  that  pressure  cannot  be  brought  to  bear 
on  it,  it  may  require  the  application  of  a  ligature  ;  but  this  should,  if 
possible,  always  be  avoided,  inasmuch  as  it  is  apt  to  occasion  dangerous 
inflammation  of  the  vessel. 

The  wound  in  a  vein  is  healed  by  slight  inflammation  taking  place 
about  the  lips  of  the  incision,  and  giving  rise  to  the  formation  of  a 
distinct  cicatrix. 

2.  In  some  cases,  from  the  irritation  of  the  simple  wound,  and  in 
others  from  the  application  of  the  ligature,  a  Diffuse  Inflammation  of 
the  Vein  takes  place,  which  usually  proves  fatal.  This  variety  of 
phlebitis  will  be  described  when  we  come  to  speak  of  the  diflferent  kinds 
of  venous  inflammation. 


228 


INJURIES  OF  BLOODVESSELS. 


3.  The  Entrance  of  Air  into  being  a  subject  of  much  impor¬ 

tance,  will  be  discussed  in  a  subsequent  chapter. 

INJURIES  OF  ARTERIES. 

Arteries  may  be  bruised,  torn,  punctured  or  cut. 

Contusion. — A  slight  bruise  of  an  artery  is  not  attended  by  any  bad 
consequences;  but,  if  the  contusion  be  severe,  obliteration  of  the  vessel 
by  adhesive  inflammation  may  ensue  some  da3’s  after  the  accident. 
Thus,  a  patient  w^as  admitted  into  Universit}"  College  Hospital  under 
Qnain,  with  a  contused  wound  in  the  axilla,  received  in  falling  upon 
some  iron  railings ;  no  change  took  place  in  the  circulation  of  the  arm 
for  two  days,  w’hen  pulsation  in  the  radial  artery  ceased,  the  injured 
vessel  having  evidentl^^  become  plugged  by  plastic  deposit. 

Rupture  and  Laceration. — An  artery  ma}"  be  torn  either  partially 
or  coinpleteh"  across.  When  Partial  Piupture  occurs,  the  internal  and 
middle  coats  onl}"  give  wa}’,  the  toughness  of  the  external  coat  pre¬ 
venting  its  laceration.  This  accident  is  especially-  apt  to  occur  in  con¬ 
sequence  of  blows  or  strains  upon  diseased  or  weakened  vessels,  and 
thus  may-  possibly-  lay-  the  foundation  for  aneurism.  In  other  cases  the 
ruptured  portion  of  the  coats  becomes  turned  down  into  the  inside  of 
the  vessel,  and,  acting  as  a  valve,  prevents  the  further  progress  of  the 
blood  through  it,  thus  giving  rise  to  gangrene  of  the  limb.  In  some 
cases  the  partially- ruptured  vessel  becomes  blocked  up  by-  plastic  matter, 
occluding  its  interior,  but  without  producing  gangrene. 

J’he  Complete  Piupture  of  an  artery-  may-  occur  either  in  an  open  wound 
or  under  the  integuments.  When  an  artery-  is  torn  across  in  an  open 
wound,  as  in  the  avulsion  of  a  limb  by-  inachineiy,  or  by  a  cannon  shot 
carry-ing  it  off,  there  is  usually-  but  little  hemorrhage,  even  from  arteries 
of  the  magnitude  of  the  axillary-  or  the  femoral,  and  though  the  vessel 
hang  out  of  the  wound,  pulsating  to  its  very-  end.  The  absence  of  bleed¬ 
ing  is  owingto  the  internal  and  middle  coats,  which  are  fragile,  breaking  off 
short  and  contracting  somewhat ;  while  the  external  coat  and  the  sheath 
of  the  vessel,  being  elastic,  are  dragged  down  and  twisted  over  the  torn 
end  of  the  artery-,  so  as  completely  to  prevent  the  escape  of  blood. 

When  the  laceration  of  the  artery-  is  subcutaneous,  as  occasionally 
happens  in  the  attempted  reduction  of  an  old  dislocation  of  the  shoulder, 
either  extensive  extravasation,  or  one  or  other  of  the  varieties  of  Trau¬ 
matic  Aneurism^  to  be  described  in  another  chapter,  may  be  produced. 

Wounds  of  Arteries,  whether  punctured  or  cut,  may-  be  divided 
into  those  that  do  not  penetrate  into  the  interior  of  the  vessel,  and  those 
by-  which  it  is  completely-  laid  open. 

Non-penetrating  Wounds  of  arteries  are  very- rare.  Guthrie, however, 
relates  the  case  of  a  gentleman  who  cut  his  throat,  and  in  whom  the 
carotid  artery-  was  exposed  and  notched  through  the  external  and  middle 
coats  only- ;  the  vessel  finally-  gave  way-  on  the  eighth  day,  death  ensuing. 
A  case  has  also  occurred  at  the  London  Hospital,  in  which  a  suicidal 
wound  of  the  throat  had  exposed  the  carotid  artery.  After  death,  it 
was  found  that  the  inner  and  middle  coats  of  the  vessel  had  been  divided 
by-  the  pressure  of  the  knife,  which  w-as  blunt,  but  that  the  external  coat 
had  been  left  entire,  and  under  this  a  dissecting  aneurism  was  found. 

In  Penetrating  Wounds  of  an  artery-,  there  is  alway-s  hemorrhage  of 
an  arterial  character,  unless  the  puncture  be  so  fine  as  to  be  closed  by 
the  mere  elasticity-  of  the  coats  of  the  vessel.  Thus,  Maisonneuve  has 
shown  that  an  artery  may-  be  punctured  with  a  fine  needle,  without  any 


HEMORRHAGE  FROM  WOUNDED  VESSELS. 


229 


hemorrhage  or  other  unfavorable  event  resulting.  If,  however,  the 
puncture  be  larger  than  this,  being  made  by  a  tenaculum  or  hook,  it 
does  not  commonly  close  in  this  way  ;  and,  if  hemorrhage  does  not  take 
place  immediately,  it  will  probably  come  on  in  the  course  of  a  few  hours 
or  days,  from  ulceration  of  the  vessel.  If  the  wound  be  still  larger, 
there  is  always  an  amount  of  immediate  hemorrhage  proportionate  to  its 
size  and  to  that  of  the  vessel. 

The  Direction  of  the  wound  in  the  artery  influences  materially  its 
characters.  If  the  cut  be  parallel  to  the  axis  of  the  vessel,  there  is  less 
tendency  to  gaping  of  the  edges  tlian  if  it  be  oblique.  In  transverse 
wounds  of  arteries,  the  retraction  of  the  coats  is  so  great  as  to  cause 
the  wound  to  assume  somewhat  of  a  circular  appearance.  If  the  artery 
be  cut  completely  across,  there  is  always  a  less  degree  of  hemorrhage 
than  when  it  is  partially  divided;  for  the  retraction  and  contraction  of 
the  cut  ends  may  then  be  sufficient  to  close  the  vessel,  which  is  not  the 
case  wdien  it  is  merely  wounded.  When  the  wound  in  the  artery  is  sub¬ 
cutaneous,  communicating  only  by  an  oblique  and  narrow  aperture  with 
the  surface,  little,  if  any,  external  hemorrhage  takes  place,  but  extrava¬ 
sation  of  blood  occurs.  The  extravasation  may  either  be  poured  into  one 
of  the  serous  cavities,  or  it  may  be  diffused  in  the  areolar  tissue  of  the 
limb  or  part,  infiltrating  it  deeply  and  extensively,  and  perhaps  by  its 
pressure  ultimately  producing  gangrene ;  or  it  may  be  effused  in  a  more 
circumscribed  manner,  giving  rise  to  one  or  other  of  the  forms  of  trau¬ 
matic  aneurism. 

HEMORRHAGE  FROM  WOUNDED  VESSELS. 

Local  Signs. — The  characters  of  the  bleeding  or  hemorrhage  differ 
according  to  the  nature  of  the  vessels  from  which  the  blood  escapes. 
When  a  Vein  is  wounded,  the  blood  that  is  poured  out  is  of  a  dark 
color,  and  flows  in  an  uniform  stream ;  the  force  with  which  this  is  pro¬ 
jected  depending  on  the  conditions  in  which  the  wounded  vein  is  placed. 
If  there  be  any  pressure  between  the  wound  and  the  heart,  as  of  a  ligature 
upon  the  vessel ;  if  the  position  of  the  part  be  such  as  to  favor  the  gravi¬ 
tation  of  the  blood  towards  the  wound;  or  if  the  muscles  of  the  limb  be 
made  to  contract,  the  force  of  the  flow  of  blood  will  be  increased. 

When  an  Artery  is  wounded,  the  blood  that  escapes  is  of  a  bright 
Vermillion  or  scarlet  color.  It  flows  by  jets,  synchronous  with  the  con¬ 
tractions  of  the  left  ventricle;  between  the  jets  the  flow  does  not  cease, 
but  the  stream  becomes  continuous.  In  the  great  majority  of  cases  the 
jet  comes  only  from  the  proximal  aperture,  dark  blood  issuing  from  the 
distal  opening  in  a  continuous  and  trickling  stream;  but  in  some  situa¬ 
tions  a  jet  of  blood  of  arterial  character  may  issue  from  the  distal  as  well 
as  from  the  proximal  end  of  the  cut  vessel,  as  in  wounds  of  the  palmar 
and  plantar  arches,  or  of  the  arteries  of  the  forearm.  As  the  blood  flows, 
the  jet  lessens  in  height,  in  consequence  of  the  w'eakening  of  the  heart’s 
action.  The  height  and  force  of  the  jet  in  all  cases  depend  greatly  on 
the  size  of  the  vessel;  thus  the  jet  from  the  femoral  arteiy  is  stronger 
than  that  from  a  muscular  branch  of  the  thigh.  When  a  small  arterial 
branch  is  wounded  near  its  origin  from  the  main  trunk,  the  jet  will  alwa^^s 
be  forcible  and  free ;  so  also  the  proximity  to  the  centre  of  the  circula¬ 
tion  will  influence  materially  the  force  with  which  the  blood  is  propelled 
from  the  wound  in  the  vessel. 

Extravasation. — When  the  blood  is  not  poured  out  on  the  surface,  but 
escapes  from  a  wounded  vessel  into  the  areolar  tissue  of  a  part,  the  sub- 


280 


INJURIES  OF  BLOODVESSELS. 


stance  of  organs,  or  internal  cavities,  it  is  termed  an  Extravasation.  In 
these  cases  there  are  not  the  ordinary  local  signs  of  an  external  hemor¬ 
rhage  ;  but  other  local  phenomena,  such  as  swelling,  dulness  on  percus¬ 
sion,  displacement  of  organs  or  parts,  discoloration  of  the  skin  and  sub¬ 
jacent  areolar  tissue,  indicate  that  blood  is  being  poured  out  subcuta¬ 
neously;  and  we  judge  of  the  quantity  of  the  blood  that  has  escaped,  not 
only  by  the  extent  of  these  local  phenomena,  but  by  the  general  effect 
produced  upon  the  system  by  its  loss. 

Constitutional  Effects  of  Hemorrhage. — These  depend  upon  the 
quantity  of  blood  lost,  on  the  rapidity  with  which  it  is  poured  out,  on 
the  state  of  the  patient’s  constitution,  and  on  the  vessel  which  furnishes 
the  bleeding. 

When  a  large  quantity  of  blood  is  suddenly  lost,  as  when  a  main 
artery  is  cut  across  or  an  aneurism  bursts,  the  patient  ma}'^  die  forth¬ 
with  ;  falling  down  in  a  state  of  syncope,  with  a  pale  cold  surface, 
lividity  about  the  lips  and  eyes,  and  a  few  gasps,  sighs,  great  restless¬ 
ness,  and  convulsive  movements  of  the  limbs  before  he  expires.  If  the 
quantity  lost  be  not  so  great  as  to  produce  death,  but  be  yet  very  con¬ 
siderable,  the  patient  becomes  faint  and  sick,  with  coldness  and  pallor 
of  the  surface,  great  restlessness  and  agitation,  thirst,  noises  in  the  ears, 
and  failure  or  complete  loss  of  sight.  If  the  quantity  lost,  though  con¬ 
siderable,  be  not  so  great  as  this,  or  spread  over  a  greater  interval  of 
time,  so  that  the  patient  is  enabled  to  rally  between  the  recurrences  of 
the  hemorrhage,  a  state  of  anaemia  will  be  induced,  characterized  by 
pallor  of  the  skin  and  of  the  mucous  membranes,  palpitation  of  the  heart, 
rushing  noises  in  the  head,  amaurosis,  a  tendency  to  syncope  when  in 
the  erect  position,  oedema  of  the  extremities,  and  general  debility  of  the 
system. 

After  excessive  loss  of  blood  the  patient  may  gradually  rally,  and,  as 
the  vital  fluid  is  reproduced  in  his  system,  he  may  recover  without  any 
bad  effects ;  or  he  may  fall  into  a  state  of  anaemia,  wdiich  may  perhaps 
never  be  completely  recovered  from,  and  may  be  associated  with  various 
forms  of  local  debility  and  disturbance  of  functions.  After  very 
abundant  loss  of  blood,  “hemorrhagic  fever”  is  apt  to  set  in,  character¬ 
ized  by  a  tendency  to  reaction  in  the  system,  with  extreme  irritability  of 
the  heart  and  arteries.  It  is  irritative  fever  conjoined  with  anaemia. 
There  is  but  a  small  quantity  of  blood  in  the  system,  and  the  heart  and 
arteries  make  violent  efforts  to  drive  it  forwards.  This  condition  is 
marked  by  the  symptoms  of  extreme  loss  of  blood,  alternating  with 
periods  of  intermittent  reaction ;  the  pulse  becomes  much  hurried, 
fluttering,  jerking,  and  irregular  in  force  and  frequency;  there  is  slight 
flushing  of  the  face  and  brilliancy  of  the  eyes,  rapidly  passing  again  into 
pallor  and  syncope ;  and  if  the  hemorrhage  eventually  prove  fatal, 
delirium  and  convulsions,  with  excessive  restlessness,  usually  precede 
death.  The  rallying  power  is  greater  in  the  young  than  in  the  old.  In 
advanced  life  blood  is  slowly  reproduced  ;  and  a  great  loss  of  so  complex 
a  fluid,  whether  by  accident  or  in  an  operation,  is  seldom  completely 
recovered  from,  and  often  leads  to  the  development  of  dangerous  or  even 
fatal  secondary  diseases  of  a  low  type.  As  has  already  been  stated  at 
1^.  2.3,  it  is  in  this  way  that  excessive  loss  of  blood  at  an  operation,  as  for 
stone  in  an  aged  man,  often  proves  indirectly  and  remotely  fatal.  The 
body  of  a  person  who  has  died  from  the  effects  of  hemorrhage  presents 
a  peculiarly  blanched,  semi-transparent,  waxen  look;  the  lips,  aim  of 
the  nose,  and  finger-nails,  have  a  somewdiat  livid  appearance,  contrasting 
strongly  with  the  clear,  yellowish-white  hue  of  the  general  surface. 


TRANSFUSION  OF  BLOOD. 


231 


Arterial  is  more  dangerous  than  venous  hemorrhage.  The  same  quantity 
of  blood  poured  out  from  a  wounded  artery  will  produce  a  greater  effect 
on  the  system  than  an  equal  loss  of  blood  from  a  divided  vein.  Children 
bear  the  loss  of  blood  badly — a  very  small  hemorrhage  may  induce  fatal 
syncope  in  infants. 

Treatment. — The  General  Tr'eatment  of  hemorrhage  is  sufficiently 
simple.  After  the  flow  of  blood  has  been  arrested  by  proper  local  means, 
such  as  will  hereafter  be  described,  the  effects  of  its  loss  are  speedily 
recovered  from  by  rest  and  good  nourishment.  In  some  cases,  however, 
the  nutritive  process  becomes  permanently  impaired,  and  a  state  of 
chronic  anaemia  is  induced ;  which,  notwithstanding  the  administration 
of  chalybeate  preparations,  may  continue  through  life,  and  terminate  in 
cachexia,  phthisis,  or  diarrhoea. 

When  the  loss  of  blood  is  considerable,  and  is  attended  by  symptoms 
of  much  prostration,  it  may  be  necessary  to  have  recourse  to  immediate 
measures  in  order  to  prevent  the  syncope  from  being  fatal.  AVitli  this 
view  the  patient  should  be  laid  recumbent,  with  the  head  low ;  and  pres¬ 
sure  ma}’-  be  exercised  upon  the  abdominal  aorta  or  the  main  arteries  of 
the  limbs,  so  as  to  confine  the  blood  as  much  as  possible  to  the  nervous 
and  circulatory  centres.  If  death  appear  imminent  from  the  effects  of 
the  hemorrhage,  as  happens  in  some  cases  of  flooding,  recourse  may  be 
had  to  transfusion  of  blood  ;  the  influence  of  which,  in  restoring  the  fail¬ 
ing  powers  of  the  heart  and  nervous  system,  is  immediate  and  most 
striking,  and  has  been  unquestionably  determined  bj^  the  observations 
of  .  Blundell  and  other  obstetricians. 

The  operation  of  Transfusion  is  one  of  some  delicacy,  and  requires 
care,  lest  mischief  be  occasioned  by  the  injection  of  air  together  with  the 
transfused  blood — an  accident  that  would  probably  prove  fatal  to  the 
patient.  If  the  proper  transfusing  apparatus,  such  as  Iligginson’s  or 
Blundell’s,  by  which  the  blood  ina}"  be  injected  without  the  risk  of  ad¬ 
mixture  of  air,  and  of  a  proper  temperature,  be  not  at  hand,  an  ordinary 
hydrocele-syringe,  capable  of  holding  about  six  ounces,  and  fitted  with 
stopcock  and  cannula,  may  be  used.  An  opening  of  sufficient  size  hav¬ 
ing  been  made  in  one  of  the  larger  veins  at  the  bend  of  the  arm  or  about 
the  instep,  and  the  cannula  having  been  introduced  for  about  an  inch, 
the  syringe,  previously  warmed,  should  be  filled,  and  about  twelve  ounces 
of  freshly  drawn  human  blood  slowly  but  steadily  injected,  the  limb  be¬ 
ing  placed  in  such  a  position  as  to  favor  its  transmission  to  the  heart. 
In  performing  this  operation,  the  principal  points  to  be  attended  to  are: 
the  proper  introduction  of  the  cannula  into  the  vein  with  as  little  injury 
as  possible  to  its  coats  ;  the  perfect  freedom  of  the  whole  apparatus  from 
bubbles  of  air  ;  and  the  steady  but  rapid  performance  of  the  operation, 
so  as  to  avoid  coagulation  and  deterioration  of  the  blood.  Panum,  of 
Copenhagen,  has  clearly  shown  by  numerous  experiments  that  the  fibrine 
is  not  in  any  way  necessary  for  the  success  of  the  operation.  He  recom¬ 
mends  that  the  blood  be  drawn  into  a  cup,  kept  warm  in  a  basin  of  hot 
water.  It  is  then  to  be  well  whipped  and  filtered  through  a  fine  cloth 
and  injected.  The  essential  part  of  the  blood  is  the  red  corpuscles,  which 
are  wanted  to  serve  as  carriers  of  oxygen.  The  removal  of  the  fibrine  in 
this  way  materially  facilitates  the  operation,  which  is  otherwise  attended 
b}^  some  difficultjq  owing  to  the  liabilitj'’  to  coagulation  of  the  blood  *n 
the  transfusing  apparatus,  or  by  danger  from  embolism  by  the  injection 
of  coagulum  into  the  veins.  If  transfusion  be  determined  on,  it  should 
not  be  delayed  until  the  last  moment,  when  the  agony  of  death  has 


232 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


already  commenced  ;  as  then  the  actions  of  the  nervous  and  circulator}' 
systems  may  be  so  impaired  that  the  patient  is  no  longer  recoverable, 
or,  if  temporaril}^  so,  will  speedily  lapse  into  a  state  of  fatal  disease. 

The  Local  Treatment  of  hemorrhage  Tvill  be  full}'  described  in  the 
next  chapter. 


CHAPTER  XIY. 

ARREST  OF  ARTERIAL  HEMORRHAGE. 

The  arrest  of  arterial  hemorrhage  is  perhaps  the  most  imx3ortant  topic 
that  can  engage  the  surgeon’s  attention,  as  on  the  safe  accomplishment 
of  this  the  success  of  every  operation  is  necessarily  dependent.  In  study¬ 
ing  this  subject  we  must  first  investigate  the  Means  that  are  adopted  by 
Aature  for  the  Suppression  of  the  Hemorrhage;  and,  secondly,  the  imi¬ 
tation  of  these  by  Surgical  Art. 

NATURAL  ARREST  OF  HEMORRHAGE. 

The  history  of  the  investigations  into  the  means  adopted  by  nature 
for  the  arrest  of  hemorrhage  is  full  of  interest  to  the  Surgeon,  and  is 
excellently  given  in  Jones’  work  on  Hemorrhage.  No  subject  in  surgery 
affords  a  stronger  evidence  of  the  advantage  of  the  application  of  “  Ex¬ 
perimental  Pathology”  to  practice,  than  this,  as  our  knowledge  of  it  has 
been  wholly  gained  by  experiments  on  the  lower  animals. 

Petit,  who  published  several  memoirs  on  this  subject  in  1731  and  fol¬ 
lowing  years,  states  that  hemorrhage  is  arrested  by  the  formation  of 
two  clots — one  outside  the  vessel,  which  he  calls  the  “  Couvercle,”  or 
Cover;  the  other  inside,  the  “Bouchon,”or  Plug — the  first  being  formed 
by  the  last  drops  of  blood  that  issue,  the  second  by  the  few  drops  that 
are  retained.  These  clots,  by  their  adhesion,  he  says,  stop  the  bleeding. 
When  a  ligature  is  applied,  a  similar  clot  forms  above  and  below  it.  He 
recommends  compression,  and  the  support  of  the  clot. 

Morand,  in  1736,  added  much  of  interest.  He  admitted  the  formation 
of  coagula,  but  insisted  on  the  changes  in  the  artery  itself ;  which,  he 
showed,  became  corrugated,  contracted,  and  retracted.  Morand  enter¬ 
tained  erroneous  views  as  to  the  structure  aud  functions  of  arteries,  but 
he  established  the  great  fact  that  changes  occur  in  the  artery  itself. 

Kirkland,  in  1763,  wrote  an  excellent  treatise  on  the  subject.  He 
showed  that  hemorrhage  was  lessened  by  swooning,  and  that  an  artery 
contracted  up  to  its  nearest  collateral  branch ;  and  he  was  of  opinion 
that  the  coagulum  did  not  arrest  the  bleeding.  His  views  were  adopted 
and  supported  by  White,  Gooch,  Aikin,  and  other  surgeons  of  his  day. 

J.  Bell  took  a  retrograde  step  by  denying  the  retraction  and  contrac¬ 
tion  of  the  artery,  and  the  importance  of  the  internal  coagulum,  and  by 
attributing  the  arrest  of  hemorrhage  solely  to  the  injecting  of  the  sur¬ 
rounding  areolar  tissue  with  blood. 

It  was  not  until  1805,  that  Jones,  by  a  series  of  admirably  conducted 
investigations,  finally  determined  the  mode  in  which  the  arrest  of  hemor¬ 
rhage  takes  place.  Since  his  time  but  little  has  been  added  to  our 
knowledge  of  the  subject,  so  complete  and  exhaustive  W'as  his  examina¬ 
tion  of  it. 


TEMPORAKY  NATURAL  MEANS. 


233 


The  Natural  Arrest  of  Arterial  Haemorrhage  is  effected  bj’’  means  that 
in  the  first  instance  are  temporary^  but  afterwards  permanent. 

Temporary  Means. — The  means  which  arrest  temporarily  the  flow 
of  blood  from  an  artery  are  threefold.  If  the  vessel  be  small,  as  the  facial 
or  radial,  they  are  sufiicient  in  many  cases  to  sta}'^  the  hemorrhage  with¬ 
out  the  interference  of  the  Surgeon;  and,  whatever  be  the  size  of  the 
vessel,  his  operations  are  materially  assisted  by  the  effort  which  nature 
makes,  though  it  may  be  an  unsuccessful  one,  to  prevent  a  fatal  escape 
of  blood.  They  consist  in  : — 

1.  The  Coagulation  of  and  an  Alteration  in  the  Constitution  of  the 
Blood. 

2.  A  Diminution  of  the  Force  of  the  Heart’s  Action,  and  consequently 
of  the  pressure  on  the  inner  coat  of  the  vessel. 

3.  Certain  Changes  effected  in  and  around  the  Artery. 

1.  The  Coagulation  of  the  Blood  in  and  around  the  wounded  artery  is 
the  first  and  most  important  means  adopted  by  nature  for  the  arrest  of 
hemorrhage.  Were  it  not  for  the  property  of  coagulation  possessed  by 
the  blood,  that  fluid  would  continue  to  drain  away  from  any  cut  artery, 
however  small,  until  life  became  extinct.  But  the  coagulation  of  the 
blood  is  sufficient  of  itself,  in  most  cases,  and  in  all  cases  of  vessels 
below  a  certain  size,  to  close  the  opening  in  the  artery,  and  so  to  arrest 
the  further  escape.  The  Alteration  that  takes  place  in  the  Blood  consists 
in  an  increase  of  its  coagulability  as  it  flows.  The  blood  that  escapes 
from  a  wounded  artery  has  from  the  first  a  tendency  to  glaze  and  coagu¬ 
late  about  the  cut  vessel,  so  as  to  offer  a  mechanical  obstacle  to  the 
further  escape  of  the  fluid.  This  of  itself  is  sufficient  in  the  smaller 
vessels  to  arrest  the  hemorrhage;  the  more  so,  as  has  been  pointed  out 
by  Hewson,  in  consequence  of  the  last  flowing  blood  being  more  coagu- 
lable  than  the  first. 

2.  The  Diminution  in  the  Force  of  the  HearVs  Action^  owing  to  the 
patient  becoming  faint  or  collapsed,  exercises  a  very  material  influence 
in  arresting  the  flow  of  blood  from  an  artery.  The  forcible  manner  in 
which  the  jet  of  blood  is  propelled  at  each  systole  of  the  ventricle,  is  the 
principal  obstacle  to  the  coagulation  of  the  blood  around  and  within  the 
cut  vessel;  for  not  only  does  the  movement  of  the  blood  prevent  coagu¬ 
lation,  but  so  long  as  the  jet  is  more  powerful  than  the  cohesion  of  the 
clot,  it  will  certainly  wash  the  coagulum  awa}'-.  As  the  blood  flows,  and 
the  heart’s  impulse  gradually  lessens  in  force,  the  jet  becomes  lower  and 
lower;  until  at  last,  when  faintness  comes  on,  it  is  almost  entirely 
arrested,  and  time  is  afforded  for  the  formation  and  the  deposit  of  a 
coagulum  in  the  vicinity  of  the  wound.  The  collapse  consequent  on 
excessive  and  sudden  loss  of  blood  may  therefore  be  looked  upon  as  one 
of  the  means  adopted  by  nature  for  the  safety  of  the  patient,  and  should 
therefore  not  be  too  speedily  counteracted  by  stimulants  or  in  any  other 
way. 

3.  The  Changes  that  take  place  in  and  around  the  Vessel  itself  are 
those  upon  which  the  final  arrest  of  the  bleeding  is  dependent.  They 
consist  in  the  Retraction  of  the  artery  within  its  sheath,  in  the  Contrac¬ 
tion  of  the  cut  ends,  and  in  the  Formation  of  a  Coagulum  around  its 
exterior,  and  in  its  interior. 

When  an  artery  is  cut  across,  it  immediately  retracts  within  its  sheath., 
the  interior  of  which  is  left  rough  and  uneven.  Through  this  uneven 
channel  the  blood  is  projected,  either  flowing  freely  externally  or  being 
extravasated  into  the  neighboring  areolar  tissue,  according  to  the  direc¬ 
tion  and  state  of  the  wound.  As  the  blood  flows  over  the  roughened 

O 


234 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


surface  of  the  sheath,  it  becomes  entangled  in  the  fibres,  and  tends  to 
coagulate  upon  them;  this  tendency  to  coagulation  is  favored  b}'  the 
increased  plasticit}^  of  the  blood  as  it  flows,  and  by  the  diminution  of 
the  propulsive  force  with  which  it  is  carried  on.  By  the  conjoined 
operation  of  these  causes  a  coagulum  is  formed,  which,  though  lying 
within  the  sheath,  is  outside  to,  aud  extends  beyond,  the  arteiy;  and  is 
hence  termed  the  external  coagulum.  It  is  usualh^  somewhat  cylidrical, 
and  often  looks  like  a  continuation  of  the  A^essel,  being  at  first  perforated 
b3'  a  hollow  track,  through  Avhich  the  stream  of  blood  continues  to  flow. 
As  it  increases,  the  hollow  becomes  closed  b}^  the  concentric  deposit  of 
coagulum.  The  hollow  track  leading  from  the  surface  of  the  coagulum 
to  the  wound  in  the  arteiy  has  been  espei^iall}'  described  and  dwelt  upon 
by  Amussat.  This  coagulum  acts  mechanically  by  blocking  up  the  end 
of  the  artery,  and  also  bj"  compressing  the  A^essel  within  the  sheath ; 
thus  constituting  the  first  barrier  to  the  hemorrhage.  The  formation 
of  the  external  coagulum  is  thus  in  a  great  measure  dependent  on  the 
retraction  of  the  arterv  within  its  sheath. 

The  next  changes  that  take  place  in  the  arteiy,  and,  indeed,  that  are 
to  a  certain  extent  simultaneous  with  those  that  have  just  been  des¬ 
cribed,  are,  its  Contraction  aud  the  formation  of  Internal  Coagulum. 

The  Contraction  of  the  cut  arteiy  commences  immediately"  after  its 
division,  and  may-  of  itself  be  sufficient  to  close  a  small  vessel.  Thus, 
daring  an  operation,  we  may"  often  see  an  arteiy  which,  when  first  cut, 
jetted  a  stream  of  blood  as  large  as  a  straw,  gradually-  contract  in  size 
until  it  ceases  to  bleed,  owing  simply-  to  this  contraction.  In  a  larger 
artery-  this  process  is  not  sufficient  to  completely-  close  the  vessel,  but 
merely-  gives  its  cut  end  a  conical  shape,  diminishing  greatly- the  aperture 
in  the  arteiy,  and  converting  it  into  a  kind  of  pin-hole. 

In  proportion  as  the  open  end  of  the  artery  is  obstructed  by  the  ex¬ 
ternal  coagulum  and  contracts  in  diameter,  the  blood  is  propelled  with 
more  aud  more  difficulty-  through  it,  until  at  last  it  escapes  in  but  a 
small  and  feeble  stream,  or  even  becomes  completely  at  rest,  allowing 
its  fibrine  to  be  deposited  in  a  slender  coagulum,  which  play-s  a  more 
important  part  in  the  permanent  than  in  the  temporary-  arrest  of  the 
bleeding.  To  the  formation  of  this  Internal  Coagulum  the  contraction 
of  the  vessel  is  subservient.  This  coagulum  is  slender  and  conical,  the 
base  being  attached  to  the  margins  of  the  aperture  in  the  vessel,  and  the 
apex  extending  upwards.  It  has  no  point  of  attachment,  except  by-  its 
base,  the  apex  and  sides  being  perfectly-  free ;  it  at  first  consists  entirely- 
of  a  firm  fibrinous  coagulum,  no  exudative  matter  entering  into  its 
composition  at  this  period,  though  important  after-changes  occur  within 
it.  The  importance  of  the  internal  coagulum  as  a  temporary-  means  of 
arresting  hemorrhage,  though  great,  has,  I  think,  been  overestimated. 
It  is  not  formed  at  all  in  certain  states  of  the  blood,  when  that  fluid  is 
devoid  of  plasticity-;  and  in  some  cases  the  proximity  of  a  collateral 
branch  to  the  cut  end  of  the  vessel  appears,  by-  preventing  the  stasis  of 
the  blood  within  it,  to  interfere  with  coagulation.  Even  when  it  is 
formed,  it  is  of  but  little  service,  so  far  as  the  primary-  arrest  of  the 
hemorrhage  is  concerned,  not  being  deposited  until  after  the  flow  of 
blood  has  been  checked  by-  other  means,  such  as  the  deposit  of  the  exter¬ 
nal  coagulum  and  the  contraction  of  the  A-essel.  After  it  is  formed,  it 
is  useful  in  acting  as  a  damper,  and  in  breaking  the  force  of  the  Avave  of 
blood  against  the  cut  end  of  the  A-essel.  It  is  in  the  permanent  arrest  of 
hemorrhage  that  the  internal  coagulum  is  of  great  importance. 

After  the  hemorrhage  from  the  cut  artery  has  been  arrested  tempo- 


PEKMANENT  CLOSURE  OF  ARTERIES. 


235 


rarily  by  the  means  that  have  been  indicated,  Nature  proceeds  to  secure 
the  vessel  by  permanently  occluding  it. 

Permanent  Closure  of  a  cut  artery  is  effected  by  two  processes  :  — 

1.  Adhesive  Inflammation  set  up  in  the  vessel  and  the  surrounding 
parts. 

2.  Continued  Contraction  of  the  artery. 

1.  Adhesion. — A  few  hours  after  the  division  of  the  artery,  l3"mph  is 
found  to  have  been  poured  out  both  within  and  on  the  outside  of  the 
injured  vessel.  The  lymph  that  is  thrown  out  within  the  vessel  forms 
the  most  important  part  of  the  internal  coagulurn,  and  tends  materially 
to  the  permanent  closure  of  the  wound.  It  is  effused  from  the  cut  sur¬ 
face  of  the  internal  and  middle  coats,  around  and  immediately  within 
the  contracted  orifice  of  the  vessel,  forming  a  small  nodule  projecting 
into  its  interior.  If  an  internal  clot  have  already  formed,  this  plastic 
nodule  is  deposited  underneath  it,  or  is  effused  into  its  base ;  if  no  tem¬ 
porary  clot  have  formed,  a  conical  mass  of  coagulurn  will  be  deposited 
upon  this  nodule,  in  obedience  to  that  law  of  patholog}'-  b}"  which  blood 
tends  to  coagulate  upon  inflamed  points.  When  fully  formed,  this  coagu- 
lum  differs  materially  in  structure  in  different  points.  At  its  base  it  is 
firm,  of  a  brownish  or  buff  color,  and  is  composed  principall}^  of  fibrine ; 
above  this  it  becomes  dark  maroon-colored,  and  ends  in  a  long  tail-like 
projection  of  simple  clot,  which  extends  up  to  the  nearest  large  collateral 
branch.  The  important  part  of  this  coagulurn,  pathologically  speaking, 
is  its  plastic  base  :  the  rest,  however  long  it  ma}'  be,  is  of  no  use  in  the 
permanent  closure  of  the  vessel ;  but,  like  the  internal  clot  already  des¬ 
cribed,  merel}’’  serves  to  break  the  shock  of  the  blood-stream. 

Coincidently  with  these  changes  in  the  interior  of  the  vessel,  impor¬ 
tant  phenomena  occur  on  its  exterior.  Inflammation  takes  place  in  the 
sheath  and  in  the  surrounding  parts,  a  round  or  ovoid  mass  of  lymph 
being  here  effused,  which  is  at  first  mixed  up  with  the  external  coagulurn  ; 
the  coloring  matter  of  this,  however,  graduall}'  becomes  absorbed, 
leaving  the  plastic  matter  accumulated  in  a  mass,  and  completely’’  block¬ 
ing  up  the  end  of  the  vessel  from  the  outside. 

2.  Contraction. — Under  the  influence  of  the  inflammation  set  up 
within  and  around  it,  the  arteiy  goes  on  contracting,  until  it  embraces 
the  included  coagulurn  so  firmly  that  it  would  appear  as  if  this  were 
adherent  to  every  part  of  it,  and  some  difficulty  is  experienced  in  sepa¬ 
rating  them.  That  the  coagulurn  and  artery  are  not  adherent  I  have 
ascertained  by  finding,  on  careful  dissection,  that  the  transverse  striae 
of  the  lining  membrane  of  the  arteiy  are  always  visible,  although  the 
coats  of  the  vessel  are  often  stained  nearly  black  by  the  imbibition  of 
the  coloring  matter  of  the  blood.  The  contracted  vessel  usually'  assumes 
a  conical  shape  ;  but  in  some  cases  I  have  seen  the  contraction  commence 
suddenly^,  the  narrowed  part  being  perfectly  cylindrical  for  the  distance 
of  about  an  inch. 

The  changes  that  have  just  been  described  are  those  which  take  place 
in  the  proximal  end  of  the  artery'.  In  the  distal  or  inferior  end,  occlu¬ 
sion  is  effected  by’-  the  same  processes  essentially^,  but  the  retraction  and 
contraction  of  the  vessel  are  not  so  complete  and  extensive,  and  the 
coagulurn  is  usually  smaller  both  inside  and  outside  ;  in  some  cases, 
indeed,  the  internal  coagulurn  is  deficient.  The  less  perfect  closure  of 
the  distal  end  may,  as  Guthrie  suggests,  be  the  cause  of  the  more  fre¬ 
quent  occurrence  of  hemorrhage  from  it. 

The  ultimate  change  that  takes  place  in  the  divided  arteiy  is  the  trans¬ 
formation  of  its  cut  extremity,  up  to  the  first  collateral  branch,  into  a 


236 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


dense  fibro-cellular  cord.  This  is  effected  b}"  the  plastic  effusion  inside 
and  outside  the  artery,  with  the  cut  and  contracted  vessel  in  the  centre, 
developing  into  fibro-cellular  tissue. 

Arrest  of  Hemorrhage  from  a  Punctured  or  Partially  Di¬ 
vided  Artery  is  effected  in  a  somewhat  different  manner  from  what  has 
been  just  now  described  ;  the  difference  consisting  in  the  changes  that 
go  on  in  the  neighborhood  of  the  wound.  If  the  wound  in  the  soft  parts 
covering  the  arteiT  be  of  small  size  and  oblique  in  direction,  so  that  the 
blood  does  not  escape  with  too  great  facilit}^,  it  will  be  found  that  the 
temporaiy  arrest  of  the  hemorrhage  takes  place  b}’  an  extravasation  of 
blood  occurring  between  the  arteiy  and  its  sheath,  by  which  the  vessel 
is  not  onh"  compressed,  but  the  relations  between  the  wound  and  the 
aperture  in  the  sheath  are  altered.  This  stratum  of  coagulated  blood 
extends  for  some  distance  within  the  sheath,  above  and  below  the  wound, 
opposite  to  which  it  is  thicker  than  elsewhere.  Coagulum  may  likewise 
be  formed  in  the  tissues  of  the  part  outside  the  sheath,  by  which  the 
vessel  is  still  further  compressed,  and  the  tendency  to  the  escape  of 
blood  proportionately  lessened. 

Tlie  permanent  closure  of  the  puncture  is  effected  by  adhesive  inflam¬ 
mation.  Lymph  may  be  effused  in  such  a  wa}’  as  to  be  sulficient  merely 
to  plug  the  wound  in  the  coats;  or  it  may  obliterate  the  whole  interior 
of  the  arteiy,  producing  complete  occlusion  of  it.  In  order  that  the 
wound  in  the  arteiy  should  unite  simph"  b3^  the  formation  of  a  cicatrix 
in  the  coats,  without  obliterating  the  cavit}''  of  the  vessel,  it  is  necessary 
that  it  be  below  a  certain  size ;  but  this  size  will  vaiy  according  to  its 
direction.  If  the  wound  be  longitudinal  or  slightl}"  oblique,  it  will  be 
more  likelj^  to  unite  in  this  way  than  if  transverse.  Guthrie  states  that, 
in  an  arteiy  of  the  size  of  the  temporal,  a  small  longitudinal  wound 
ma}^  sometimes  heal  without  obliteration  of  the  vessel,  though  this  very 
rarel}’’  happens  in  larger  arteries.  If  a  large  vessel,  such  as  the  femoral, 
be  opened  longitudinall}"  to  the  extent  of  one-fourth  of  its  circumference, 
there  is  no  proof  tliat  the  wound  can  heal  without  obliteration  of  the 
cavity  of  the  arterj" ;  but  when  a  longitudinal  wound  in  a  large  arteiy  is 
veiy  small,  little  more  than  a  puncture,  closure  may  possibly  take  place 
simplj'  b}^  its  cicatrization.  The  plastic  matter  forming  the  cicatrix  is 
thrown  out  tlie  external  coat  of  the  arteiy.  The  internal  and  middle 
coats  do  not  unite  strongh",  the  aperture  in  them  being  merely  filled  up 
b}'  a  plug  of  l^nnph  ;  hence  the  arteiy  alwa3^s  continues  weak  at  this 
point,  and  ma}’’  eventually'  become  aneurismal. 

If  an  artery  of  the  second  or  third  magnitude,  as  the  axillaiy  or 
femoral,  be  divided  to  one-fourth  or  more  of  its  circumference,  either 
fatal  hemorrhage  or  the  formation  of  a  traumatic  aneurism  will  take 
place,  according  to  the  size  and  more  or  less  direct  character  of  the 
external  wound.  In  those  comparatively^  rare  cases,  however,  in  which 
the  hemorrhage  is  arrested  without  these  consequences  ensuing,  it  will 
be  found  that  it  is  so,  by  the  vessel  becoming  obliterated  by"  a  plug  of 
ly-mph,  which  is  poured  out  at  the  wounded  part  and  gradually  encroaches 
on  the  cavity'  of  the  arteiy,  until  complete  obliteration  is  produced,  and 
the  vessel  at  the  seat  of  obstruction  becomes  converted  into  a  fibro- 
cellular  cord. 

SURGICAL  TREATMENT  OF  ARTERIAL  HEMORRHAGE. 

The  object  of  the  Surgeon,  in  any  means  that  he  adopts  for  the  sup¬ 
pression  of  arterial  hemorrhage,  is  to  imitate,  hasten,  or  assist  the  natural 


APPLICATION  OF  THE  TOUKNIQUET. 


237 


process,  or  to  excite  analogous  ones.  All  his  means  act  by  one  or  other 
of  the  following  methods:  1.  By  increasing  the  retraction  and  contrac¬ 
tion  of  the  arterial  coats ;  2.  By  forming  an  artificial  coagulum ;  3.  By 
excitino-  adhesive  infiammation  in  and  around  the  vessel. 

O 

The  danger  from  arterial  hemorrhage,  and  the  measures  that  must  be 
adopted  to  meet  it,  vaiy  according  to  the  size  of  the  vessel.  In  all  cir¬ 
cumstances  the  Surgeon  should  bear  in  mind  the  excellent  advice  given 
by  Guthrie,  never  to  fear  bleeding  from  an}'  artery  on  which  he  can  lay 
his  finger  ;  the  pressure  of  this  readily  controlling  the  bleeding  from  the 
largest  vessels,  provided  it  can  be  fairly  applied,  or  the  cut  end  of  the 
artery  seized  between  the  finger  and  thumb.  Thus,  in  amputation  at 
the  hip  and  shoulder-joints,  the  assistant  readily  controls  the  rush  of 
blood  from  the  femoral  and  axillaiy  arteries  b}"  grasping  them  between 
his  fingers.  Above  all,  the  Surgeon  should  never  dread  hemorrhage,  nor 
lose  his  presence  of  mind  wdien  it  occurs.  If  recourse  be  had  to  efiectual 
means  for  its  suppression,  it  can  alwaj’s  be  at  least  temporarily  arrested. 
And  on  no  account  should  an}"  one  who  pretends  to  the  character  of  a 
Surgeon  have  recourse  to  inefficient  means  to  stop  it,  and  imagine  that 
he  can,  by  covering  up  the  wound  with  rags,  handkerchiefs,  etc.,  prevent 
the  escape  of  blood.  These  means  only  hide  the  loss  that  is  going  on, 
and,  by  increasing  the  warmth  of  the  parts,  prevent  the  contraction  of 
the  vessels,  and  favor  the  continuance  of  the  bleeding.  In  all  circum¬ 
stances,  therefore,  bleeding  wounds  should  be  opened  up,  the  coagula 
gently  removed  from  their  surface  by  means  of  a  piece  of  soft  sponge  or 
a  stream  of  cold  water,  and  the  part  well  cleaned.  In  this  way  you 
look  your  enemy  in  the  face,”  and  can  adopt  efficient  means  for  the  per¬ 
manent  arrest  of  the  hemorrhage. 

The  flow’  of  blood  through  a  limb  may  be  controlled  for  a  temporary 
purpose,  as  during  an  operation,  by  the  compression  of  the  main  artery 
by  the  hands  of  an  assistant.  This  maybe  done  in  the  lower  extremity 
by  pressing  the  femoral  artery  against  the  brim  of  the  pubic  bone,  and 
in  the  upper  extremity  by  compressing  the  subclavian  against  the  first 
rib,  or  the  brachial  against  the  shaft  of  the  humerus.  The  pressure 
should  be  made  by  grasping  the  limb  with  one  hand  in  such  a  way  that 
the  thumb  bears  upon  the  artery,  and  presses  it  directly  against  the  sub¬ 
jacent  bone.  If  the  limb  be  large,  or  if  long-continued  pressure  be 
required,  the  thumb  of  the  other  hand  should  be  firmly  applied  upon 
that  which  is  already  compressing  the  vessel  (Fig.  91).  In  some  cases, 
especially  when  the  subclavian  or  external  iliac  requires  to  be  com¬ 
pressed,  the  handle  of  a  large  key,  or  the  end  of  a  desk  seal,  covered 
with  leather,  will  be  found  the  most  convenient  instrument  for  applying 
the  pressure. 

In  particular  and  exceptional  instances,  where  the  artery  has  become 
unusually  deep  seated — as,  for  instance,  where  the  clavicle  has  been 
pushed  up  above  the  subclavian  by  an  aneurismal  tumor — and  when 
ordinary  means  fail  in  effecting  a  secure  compression  of  the  vessel,  a  very 
effectual  mode  of  controlling  the  flow  of  blood  through  it  has  been 
adopted  by  Syme.  This  consists  in  making  an  incision  through  the 
skin  and  superficial  fascia  over  the  artery,  so  that  the  fingers  of  the 
assistant  may  be  brought  to  bear  almost  directly  upon  the  vessel,  w’hich 
may  thus  be  securely  and  effectually  compressed. 

In  most  cases,  however,  in  which  temporary  compression  of  the  artery 
is  required,  the  Tourniquet  should  be  employed.  It  is  far  safer  to  trust 
to  this  instrument,  than  to  the  hands  of  an  assistant,  however  steady 
and  strong.  When  the  tourniquet  is  applied  with  a  sufficient  degree  of 


238 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


tightness,  the  whole  circulation  through  the  limb  may  be  completely 
arrested.  This  can  never  be  done  by  the  compression  of  the  main  trunk 
alone,  the  collateral  and  minor  supplying  vessels  conveying  blood  into 
the  limb  independently  of  it.  Then  again,  if  the  operation  be  unex- 


Fig.  91. 


Pressure  with  Thumbs.  Application  of  Tourniquet  to  Femoral  Artery, 


pectedl}’  protracted  from  an}-  cause,  the  fingers  of  an  assistant  may  tire 
or  stiffen ;  and,  the  steadiness  of  their  pressure  becoming  relaxed, 
hemorrhage  may  ensue.  For  these  reasons.  Surgeons  almost  invariably 
employ  the  tourniquet  in  amputations;  and  even  Liston,  who  at  one 
period  of  his  career  discarded  this  instrument,  commonly  employed  it 
during  the  latter  years  of  his  life.  In  applying  the  tourniquet,  care 
should  be  taken  not  to  screw  it  up  until  the  very  moment  when  the  com¬ 
pression  is  required,  and  then  to  do  so  quickly  and  with  considerable 
force,  lest  venous  congestion  of  the  limb  take  place,  by  the  veins  being 
compressed  before  the  circulation  in  the  arteries  is  arrested. 

The  different  means  that  maybe  employed  for  'permo.nent  arrest  of 
hemorrhage  are,  1,  the  Application  of  Cold  ;  2,  Stj’ptics ;  3,  Cauteriza¬ 
tion  with  the  Hot  Iron;  4,  Pressure;  5,  Flexion  ;  6,  Torsion;  t.  Liga¬ 
ture  ;  and  8,  Acupressure. 

I.  Application  of  Cold  is  sufficient  to  arrest  the  general  oozing  of 
arterial  blood  which  is  always  observed  on  a  cut  surface.  The  mere  ex¬ 
posure  of  a  wound,  which  has  bled  freel}'  so  long  as  it  has  been  covered 
up  b}^  pledgets  and  bandages,  to  the  cold  air,  is  often  sufficient.  When 
this  does  not  succeed,  the  application  of  a  piece  of  lint,  soaked  in  cold 
water,  will  usuall}’  arrest  the  flow  of  blood.  When  it  is  necessary  to 
do  this  speedil}",  as  in  some  operations  about  the  air-passages,  a  small 
stream  of  cold  water  may  be  allowed  to  drip  into  the  wound,  and  thus 
cause  rapid  contraction  of  the  vessels,  and  consequent  cessation  of 
bleeding.  In  cases  of  bleeding  into  some  of  the  hollow  cavities  of  the 
body,  as  the  rectum,  vagina,  or  mouth,  the  application  of  ice  is  advan¬ 
tageous.  Its  use  should  not,  however,  be  too  long  continued,  lest 
sloughing  occur.  Indeed,  if  cold  do  not  speedily — almost  at  once — arrest 


DIEECT  PEESSURE. 


239 


the  bleeding  by  constricting  the  vessels,  it  is  better  to  have  recourse  to 
other  and  more  efficient  means. 

2.  Styptics  aid  powerfully  the  contraction  of  the  vessels,  and,  by 
increasing  the  rapidity  of  formation  and  the  firmness  of  the  coagulam, 
tend  to  arrest  the  hemorrhage  ;  they  are  principally  used  in  oozing  from 
spongy  parts,  or  in  bleeding  from  cavities  or  organs  to  which  other  ap¬ 
plications  cannot  readily  be  made.  The  great  objection  to  their  employ¬ 
ment  in  some  wounds  consists  in  their  tendency  to  modify  injuriously 
the  character  of  the  surface,  and  to  prevent  union  by  the  first  intention. 
The  most  useful  styptics  are  the  solution  of  perchloride  of  iron,  spirits 
of  turpentine,  gallic  acid,  and  matico ;  the  application  of  alum,  or 
touching  a  bleeding  part  with  a  pointed  stick  of  the  nitrate  of  silver  is 
also  serviceable.  Of  all  these,  the  solution  of  the  perchloride  of  iron, 
when  injected  into  or  applied  upon  a  bleeding  part,  acts  as  the  readiest 
and  most  efficient  hsemostatic,  coagulating  the  blood  with  remarkable 
rapidit}^,  and  into  a  very  firm  clot.  In  order  to  apply  this  or  any  other 
styptic  efiectually,  the  part  should  be  wiped  dry,  all  coagula  removed, 
and  a  piece  of  lint  or  cotton-wool  soaked  in  the  solution  and  then 
squeezed  nearly  dry,  firmly  applied  and  maintained  by  the  pressure 
either  of  the  finger  or  of  a  pad  and  bandage.  If  the  bleeding  proceed 
from  a  mucous  canal,  that  should  be  firml}’-  plugged  with  the  lint  so 
prepared. 

3.  Cauterization  by  means  of  the  red-hot  iron  w’as  almost  the  only 
mode  of  arresting  arterial  hemorrhage  that  was  known  to  the  ancients. 
It  is  now  comparatwely  seldom  eihployed,  but  yet  in  many  cases  it  is 
of  the  most  unquestionable  utility,  and  superior  to  any  other  means  that 
we  possess  ;  more  particularly  in  those  cases  in  which  the  hemorrhage 
proceeds  from  a  soft  and  porous  part  that  will  not  hold  a  ligature,  or 
from  the  surface  of  which  many  points  appear  to  be  bleeding  at  the 
same  time.  A  somewhat  conical  iron  of  sufficient  size  should  be 
used,  and  the  hemorrhage  will  often  be  stayed  more  effectually  if  it  be 
applied  at  a  black,  than  at  a  red  or  white  heat.  As  the  actual  cautery 
blocks  up  the  artery  b}'  a  thick  slough  or  eschar,  there  is  alwa3^s 
danger  of  a  recurrence  of  the  bleeding  when  this  separates,  and  the 
Surgeon  must  be  on  his  guard  about  the  sixth  or  eighth  day  lest  it 
break  out  again. 

4.  Direct  Pressure  upon  the  bleeding  part  is  a  very  efficient  mode 
of  arresting  hemorrhage  from  small  arteries.  It  is  not,  however,  appli¬ 
cable  to  all  parts  of  the  body,  as  it  is  necessary  that  the  vessel  should 
have  a  bone  subjacent  to  it,  so  as  to  afford  a  point  of  counterpressure; 
hence  it  cannot  readily  be  emploj^ed  in  soft  and  movable  parts,  as  the 
throat  or  perinseum.  Pressure  may  be  practised  in  various  ways. 
Sometimes  the  mere  uniform  compression  of  a  bandage  is  sufficient  to 
arrest  the  hemorrhage  ;  thus  oozing  from  a  wound  may  often  be  stopped 
by  la^dng  down  the  flaps,  and  applying  a  bandage  rather  tightly  over 
them.  Sometimes  a  weight  applied  upon  this  wdll  tend  still  further  to 
arrest  the  bleeding ;  as,  for  instance,  bj"  means  of  a  shot  or  sand-bag 
laid  upon  the  part.  In  the  case  of  bleeding  from  hollow  cavities,  as  the 
rectum,  vagina,  or  nares,  the  hemorrhage  may  be  arrested  b}^  the  pres¬ 
sure  of  a  plug  of  sponge  or  lint,  to  which  sometimes  a  styptic  may 
advantageously  be  added.  When  the  hemorrhage  proceeds  from  the 
puncture  of  a  small  or  moderate-sized  artery,  as  of  the  temporal  or 
brachial,  pressure  should  be  made  against  the  adjacent  bone  by  means  of 
a  graduated  compress  and  bandage,  and  should  be  continued  until  com¬ 
plete  consolidation  of  the  wound  has  taken  place,  the  vessel  becoming 


240 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


obliterated.  The  gr'aduated  compress  should  be  at  least  an  inch  in 
thickness,  and  made  of  a  series  of  pledgets  of  lint  of  a  circular  shape, 
gradually  diminishing  in  size.  It  should  be  applied  with  its  pointed  end 
resting  over  the  wound  in  the  vessel.  In  applying  it,  care  should  be 
taken  that  the  part  on  which  the  pressure  is  to  be  exercised  has  been 
thoroughl3^  dried  of  all  blood,  and  that  the  artery  is  commanded  above 
the  wound  bj^  a  tourniquet,  or  by  the  pressure  of  an  assistant’s  fingers. 
A  thick  slice  of  a  phial-cork,  or  a  fourpenn}^  piece,  wrapped  in  lint, 
being  placed  on  the  wound,  the  graduated  compress  should  be  bandaged 
tightl}'  over  the  whole.  AYhen  applied  in  this  wa}",  pressure  acts  by 
inducing  adhesive  inflammation  aud  obliteration  of  the  vessel  at  the 
point  compressed. 

5.  Forcible  Flexion,  as  a  means  of  arresting  hemorrhage  from  the 
arteries  of  the  limbs,  has  in  recent  3^ears  been  advocated  bj^  Heath,  of 
Newcastle,  Adelmann,  of  Dorpat,  and  others.  Its  application  is  founded 
on  the  fact,  specially”  pointed  out  in  1823  b^’  Forme}^,  that  flexion  of  the 
arm  at  the  elbow-joint  weakens  or  arrests  the  pulsation  at  the  wrist. 
Malgaigne,  Tidal,  Fleuiy,  Fiy,  and  some  other  Surgeons,  have  reported 
cases  in  which  the  plan  was  emploved  successful!}^ ;  but  until  lately  the 
method  has  attracted  little  attention.  Heath,  from  a  number  of  experi¬ 
ments  made  by  him  in  the  Newcastle  Infirmary,  has  found  that  flexion 
of  the  arm  at  the  elbow,  or  of  the  leg  at  the  knee,  diminishes  or  arrests 
the  pulse  in  the  distant  arteries.  In  this  respect  he  confirms  the  obser¬ 
vations  of  Hyrtl  and  others ;  but  he  finds  also  that  in  the  arm  the  pro¬ 
cess  is  greatly  aided  by  placing  a  pfece  of  lint  or  a  handkerchief  rolled 
up  in  the  bend  of  the  elbow  ;  and  in  the  lower  limb,  by  bending  the 
thiorh  on  the  abdomen  at  the  same  time  that  the  leg  is  bent  at  the  knee. 
Where  flexion  acts  successfully  as  a  means  of  h?emostasis  —  as  it  is 
reported  to  have  done  in  several  cases,  especially  in  wounds  of  the 
palmar  arteries  and  the  vessels  of  the  forearm — it  probably  does  so  by 
weakening  the  current  of  blood,  so  as  to  favor  the  closure  of  the  arterial 
wound  in  the  manner  described  in  speaking  of  the  Natural  Arrest  of 
Hemorrhage.  The  apparent  simplicity  and  safety  (when  carefully  ap¬ 
plied)  of  flexion  render  it  worthy  of  further  trial  in  cases  of  injury  of 
the  arteries  of  the  forearm  and  hand  or  of  the  leg  and  foot.  A  roll  of 
lint  or  other  soft  material  having  been  placed  in  the  flexure  of  the  joint, 
the  limb  should  be  bent  until  it  is  perceived  that  the  hemorrhage  is 
arrested,  and  should  then  be  maintained  in  position  by  means  of  a  hand¬ 
kerchief  or  bandage.  Care  must  of  course  be  taken  not  to  exercise  too 
great  compression,  by  which  gangrene  might  be  produced.  The  flexion 
should  be  kept  up  till  the  Surgeon,  by  careful  examination,  is  satisfied 
that  there  is  no  further  risk  of  hemorrhage. 

6.  Torsion  of  Cut  Arteries  for  the  arrest  of  hemorrhage  is  men¬ 
tioned  by  Galen  ;  but  the  practice  seems  to  have  been  forgotten  until 
about  1828.  It  was  revived  in  France  by  Amussat,  Velpeau,  and 
Thierry  ;  and  in  Germany  by  Fricke,  who  experimented  upon  and  prac¬ 
tised  this  method  of  treating  divided  arteries,  with  much  ingenuity  and 
perseverance.  But,  notwithstanding  the  efforts  made  to  force  it  on  the 
attention  of  Surgeons,  it  was  gradually  abandoned,  even  by  its  strongest 
advocates.  Torsion  has  never  found  much  favor  amongst  Surgeons  in 
this  country,  and  has,  perhaps,  been  too  much  neglected.  Of  late  years 
it  has,  however,  again  been  revived,  chiefly  in  connection  with  and  by 
the  advocates  of  the  “Antiseptic  Treatment,”  and  by  those  who  have 
been  anxious  to  do  away  with  the  use  of  the  ligature,  as  being  injurious 
in  many  ways,  and  more  especially  in  regard  to  the  direct  union  of 


TORSIOX  OF  ARTERIES. 


241 


wounds,  particularly  in  plastic  and  other  similar  operations  where  the 
presence  of  a  ligature  is  very  liable  to  occasion  irritation  and  suppu¬ 
ration. 

Torsion  may  be  practised  in  various  ways.  Thus,  Amussat  recom¬ 
mends  that  the  artery  be  drawn  out  for  about  half  an  inch  by  one  pair 


Fig.  92. 


of  forceps  ;  that  it  then  be  seized  at  its  attached  end  with  another  for¬ 
ceps,  and  that  the  end  be  twisted  off  b}’  about  a  dozen  turns.  Velpeau 
and  Fricke  advise  that  the  end  be  not  taken  off,  but  merel}'  twisted 
seven  to  eight  times,  according  to  the  size  of  the  vessel.  Thieriy  simph’ 
seizes  the  artery  and  twists  it  in  the  direction  of  its  axis.  In  seizing 
the  artery  it  is  peculiarl}’^  important,  as  Dupiytren  has  i)ointed  out,  that 
the  whole  vessel  be  grasped  b}'  the  forceps,  and  that  care  be  taken  not 
to  introduce  one  blade  into  the  open  end  of  the  vessel,  and  thus  only 
twist  half  of  it.  There  can  be  no  doubt  that  hemorrhage  from  the 
largest  vessels  may  be  efficient!}"  stopped  by  torsion.  Amussat  and 
Velpeau  repeatedly  used  it  to  close  the  femoral,  brachial,  ulnar,  and 
radial  arteries  in  amputations  of  the  thigh,  arm,  and  forearm. 

In  torsion  an  artery  is  placed  in  the  condition  of  one  that  is  lacerated 
or  torn  through  The  internal  and  middle  coats  are  retracted,  and  the 
external  one  is  twisted  into  a  kind  of  screw*  beyond  them.  A  coagulum 
next  forms  within  the  vessel,  blocking  up  its  extremity;  inflammation 
then  takes  place,  gluing  together  the  coats  of  the  artery ;  the  twisted 
end  sloughs  off,  and  the  vessel  becomes  occluded  up  to  the  nearest 
collateral  branch. 

The  employment  of  torsion  as  a  substitute  for  the  ligature  is  advo¬ 
cated  on  three  grounds:  1,  that,  whilst  equally  safe,  it  is  more  easy  of 
application  ;  2,  that  it  is  less  liable  to  be  followed  by  secondary  hemor¬ 
rhage;  and  3,  that  wdien  an  artery  is  closed  by  torsion,  no  foreign  body 
is  left  in  the  w-ound  that  could  interfere  with  its  direct  union. 

VOL.  I _ 16 


242 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


Let  US  briefly  examine  these  assumed  advantages  of  torsion  over  the 
ligature. 

1.  So  far  as  ease  of  application  is  concerned,  there  can  be  no  doubt 
that  the  advantage  is  in  favor  of  the  ligature.  This  is  especially  and 
very  markedly  the  case  with  small  vessels  and  those  that  cannot  be 
drawn  out  of  a  sheath.  In  the  case  of  the  larger  arteries,  that  can  be 
denuded  and  drawn  out  of  the  neighboring  tissues,  it  is  at  least  as  easy 
to  throw  a  thread  around  the  exposed  vessel  as  to  twist  it  up  securely. 

2.  With  reference  to  the  comparative  freedom  from  secondary  hemor¬ 
rhage,  we  have  few  data.  This  accident  so  rarely  follows  the  use  of  the 
ligature  in  open  wounds,  that  it  is  scarcely  to  be  taken  into  account  as 
a  source  of  danger;  and  when  it  does  occur,  it  arises  from  causes,  such 
as  a  diseased  state  of  the  tissues  and  blood,  that  are  equally  independent 
of  ligature  and  of  torsion.  And  if  secondary  hemorrhage  rarely  follows 
torsion  of  an  artery,  the  same  may  be  said  with  equal  truth  with  respect 
to  its  ligature. 

3.  The  torsion  of  arteries  was  strongly  advocated  on  the  ground  that, 
whilst  equally  as  safe  as  the  ligature,  there  would  after  its  employment 
be  less  liability  to  inflammation  and  suppuration,  as  no  foreign  body  was 
left  in  the  wound.  This  argument  was  especially  urged  by  Amiisat,  who 
states  that,  as  the  employment  of  torsion  reduces  the  inflammation  and 
suppuration  of  a  wound  almost  to  nothing,  the  cicatrization  must  neces¬ 
sarily  be  more  rapid.  This  statement,  however,  was  not  borne  out  bj^ 
experience ;  and  no  difference  was  observable  in  that  respect  between 
the  healing  of  wounds  in  which  the  vessels  had  been  tied  and  those  where 
they  had  been  twisted.  It  was  hence  considered  that  the  advantage 
assumed  for  torsion  over  the  ligature  in  this  respect  was  more  fanciful 
than  real;  and  Velpeau,  who  was  one  of  its  earliest  and  staunchest  ad¬ 
vocates,  admitted,  after  a  prolonged  experience  of  it,  that  torsion  w^as 
not  applicable  in  every  case,  and  that  in  none  did  it  possess  any  real 
n.dvantage  over  the  ligature. 

The  question  as  to  the  injurious  influence  exercised  by  the  ligature  as 
■3,  foreign  body  in  the  healing  of  wounds  will  be  discussed  when  we  come 
to  compare  the  relative  merits  of  acupressure  and  the  ligature  as  means 
of  arresting  hemorrhage  (p.  251).  But  the  question  as  to  whether,  in 
■employing  torsion,  we  completely  clear  the  wound  of  all  foreign  bodies 
and  succeed  in  preventing  the  injurious  interposition  of  a  substance 
that  is  detrimental  to  the  healing  process,  may  be  considered  here.  We 
must  discuss  this  question  according  as  torsion  is  applied  to  the  larger 
.or  to  the  smaller  arteries. 

When  a  large  arteiy,  such  as  the  femoral  or  brachial,  is  twisted  for 
the  arrest  of  hemorrhage,  it  is  drawn  out  of  its  sheath,  the  vascular  con¬ 
nections  with  which  are  disturbed  or  broken  through ;  the  end  that  is 
twisted  is  severely  pinched  and  bruised ;  the  internal  and  middle  coats 
are  broken  through  and  turned  back,  whilst  the  external  one  is  screwed 
into  a  tight  twist  beyond  these  ;  and  this,  together  with  the  turning 
back  of  the  separated  internal  and  middle  coats,  forms  the  obstacle  to 
the  escape  of  blood,  the  coagulum  forming  above  this  point  exactlj^  as 
in  the  case  of  a  ligatured  artery.  Manec,  in  his  classical  work  on  the 
ligature  of  the  arteries,  wrote  as  follows :  “  The  extremity  of  the  twisted 
artery  and  the  fragments  of  the  internal  and  middle  coats  constitute  a 
foreign  body ; — these  parts  of  the  vessel,  being  severely  bruised  by  the 
torsion,  maintain  no  connection  with  the  surrounding  tissues,  are  unable 
to  form  aii}^  adhesion  to  them,  and  can  only  be  removed  by  the  conjoined 
action  of  suppuration  and  absorption.”  Manec  further  states  as  the 


LIGATUKE  OF  WOUNDED  ARTERIES. 


243 


result  of  his  experiments  that,  when  he  applied  the  ligature  to  the  main 
artery  of  the  limb  and  employed  torsion  upon  the  corresponding  vessel 
of  the  other,  he  almost  always  found  that  the  wound  cicatrized  more 
easily  when  the  artery  was  tied  than  when  it  was  twisted.  Thus  it  would 
appear  that  the  result  of  practical  experience  and  of  experiment  tend  to 
show  that  the  twisted  end  of  a  large  artery  is  in  reality  a  foreign  body ; 
and  that  in  this  respest  torsion,  when  applied  to  the  principal  arteries 
of  a  limb,  presents  no  advantage  over  the  ligature. 

But  the  case  is  undoubtedl}'  different  with  the  smaller  arteries.  Here 
the  vessel  need  not  be  drawn  out  or  detached  from  surrounding  parts ; 
and  consequentl3’  there  is  not  the  same  injuiy  inflicted  upon  its  free  end. 
The  mere  pinching  and  moderate  twisting  of  the  bleeding  point  will  be 
sufficient  to  arrest  the  hemorrhage  from  it.  And  in  these  cases,  but  in 
these  onl}’^,  torsion  appears  to  me  to  possess  a  decided  advantage  over 
the  ligature.  This  is  more  particularly  the  case  when,  as  in  plastic  ope¬ 
rations,  direct  union  is  of  the  first  importance,  and  the  presence  of  the 
knot  and  thread  of  the  ligature  would  infallibly  leave  a  suppurating 
track. 

There  is  one  condition  of  an  artery  that  is  an  insuperable  obstacle  to 
the  successful  employment  of  torsion,  viz.,  the  calcification  of  its  coats. 
In  such  cases  thick  ligatures  can  alone  be  used  with  safety. 

7.  Ligature  is  the  means  to  which  Surgeons  commonl}^  have  recourse 
for  the  arrest  of  hemorrhage  from  wounded  arteries. 

The  Ligature  had  been  occasionallj’^  and  partially  employed  by  the 
later  Roman  Surgeons  ;  but  with  the  decline  of  Surgery  it  fell  completely 
into  disuse,  giving  way  to  such  barbarous  and  inefficient  modes  of 
arresting  the  hemorrhage  as  the  employment  of  the  actual  cautery,  the 
performance  of  operations  wdtli  red-hot  knives,  or  the  application  of 
boiling  pitch,  or  of  molten  lead,  to  the  bleeding  and  freshly  cut  surface. 
About  the  middle  of  the  sixteenth  century  it  was  revived  or  reinvented 
b}^  that  great  luminary  of  the  French  school  of  Surgery,  Ambroise 
Pn’e.  But  so  slowly  did  the  ligature  make  wa}^  amongst  Surgeons,  that 
Sharpe,  Surgeon  to  Guy’s  Hospital,  writing  in  1761,  two  centuries  after 
its  introduction  into  practice  by  Pare,  found  it  necessary,  in  his  well- 
known  work,  entitled,  “A  Critical  Enquiiy  into  the  Present  State  of 
Surgery,”  formally  to  advocate  its  employment  for  the  arrest  of  hemor¬ 
rhage  from  wounded  arteries,  in  preference  to  styptics  or  the  cautery,  on 
the  ground  that  “  it  was  not  as3’et  universally  practised  among  Surgeons 
residing  in  the  more  distant  counties  of  our  kingdom.”  What,  it  may 
be  asked,  was  the  reason  that  it  took  two  centuries  to  promulgate  the 
use  of  the  simplest  and  most  efficacious  means  we  possess  in  surgery 
for  the  arrest  of  hemorrhage — a  simple  tying  up  of  a  spouting  artery — 
a  means  that  no  Surgeon  could  now  for  a  da^"  dispense  with  ?  The 
reason  simply  was,  that  Surgeons  were  totall}’’  ignorant  of  the  means 
emplo\'ed  b^^  Nature  for  the  occlusion  of  arteries  ;  that  the}"  consequently 
knew  not  how  to  apply  a  ligature  to  these  vessels,  or  what  kind  of  liga¬ 
ture  should  be  used;  and  that,  in  their  anxiety  to  avoid  the  recurrence 
of  secondar}'  hemorrhage,  and  to  make  all  safe,  the}"  fell  into  the  very 
errors  they  should  have  avoided,  had  they  been  acquainted  with  the 
physiology  of  the  processes  which  Nature  employs  for  the  closure  of  the 
artery  and  the  separation  of  the  thread. 

Between  twenty  and  thirty  years  after  the  time  at  which  Sharpe  wrote, 
we  find  that  Hunter  introduced  that  great  improvement  in  the  surgical 
treatment  of  aneurism — the  deligation  of  the  artery  at  a  distance  from 
the  sac,  and  in  a  healthy  part  of  its  course ;  but  this  great  accession  to 


244 


AEREST  OF  ARTERIAL  HEMORRHAGE. 


the  treatment  of  a  most  formidable  disease  was  but  coldly"  received,  and 
ran  some  risk  of  being  lost  to  the  world  in  consequence  of  the  ill-success 
that  attended  the  earlier  operations.  In  Hunter’s  first  operation,  four 
ligatures  were  used,  all  of  which  were  applied  so  slackly  as  merely  to 
compress  the  artery  for  some  distance,  and  to  avoid  too  great  a  degree 
‘of  pressure  at  any  one  point;  the  artery  was  denuded,  so  that  a  spatula 
could  be  passed  under  it.  Althougli  in  his  subsequent  operations  Hun¬ 
ter  contented  himself  with  employing  but  one  ligature,  yet  sometimes 
the  vein  was  included  in  this;  and  he  did  not  draw  the  noose  tightl}^  for 
fear  of  injuring  the  coats  of  the  vessel,  in  accordance  with  the  doctrine 
of  the  day — Surgeons  generally  at  this  time  being  haunted  with  the 
dread  of  injuring,  and  thereby  weakening,  the  coats  of  the  arteiy ;  and, 
in  order  to  avoid  doing  so,  adopting  modes  of  treatment  that  almost 
infallibly  led  to  ulceration  of  the  vessels  and  consecutive  hemorrhage. 
The  application  of  several  ligatures  of  reserve,  applied  slack — the  use  of 
broad  tapes — the  interposition  of  plugs  of  cork,  wood,  agaric,  or  lead,  or 
of  rolls  of  lint  or  plaster,  between  the  thread  and  the  vessel,  were  some 
amongst  the  plans  that  were  in  common  use.  And  how  can  we  be  sur¬ 
prised  that  the  patients  perished  of  hemorrhage,  and  that  ligature  of  the 
vessel  was  nearly  as  inefficient  and  fatal  a  means  of  arresting  bleeding 
as  the  Tise  of  a  cautery  or  of  a  button  of  white  vitriol? 

Jones,  by  an  appeal  to  experiment,  and  by  means  of  a  series  of  admira¬ 
bly  conducted  investigations,  showed  that  the  very  point  which  Surgeons 
were  anxious  to  avoid — the  division  of  the  coats  of  the  vessel  by  the 
tightening  of  the  noose — was  that  on  which  the  patient’s  safety  depended; 
he  also  pointed  out  the  form  and  size  of  ligature  that  was  most  safe, 
the  degree  of  force  with  which  it  should  be  applied,  and  the  processes 
adopted  by  nature  for  the  occlusion  of  the  vessel.  Then  a  more  rational 
practice  was  introduced,  and  then,  for  the  first  time.  Surgeons  had  full 
confidence  in  the  use  of  the  ligature. 

Principles  of  Treatment  of  Wounded  Arteries. — The  whole  of  the  doc¬ 
trine  of  the  general  treatment  of  wounded  arteries  by  ligature  maj'^  be 
included  in  two  great  principles  :  1,  To  cut  directly  down  on  the  wounded 
paid.,  and  to  tie  the  vessel  there ;  and  2,  To  apj)ly  a  ligature  to  both  ends., 
if  it  he  completely  divided.,  or  to  the  distal  as  well  as  the  proximal  side  of 
the  wound.,  if  it  be  merely  punctured. 

These  principles  of  treatment  were  distinctly  laid  down  by  John  Bell;^ 
but,  although  this  great  Surgeon  inculcated  forcibly  these  rules  of  prac¬ 
tice,  Surgeons  appear  to  have  been  led  away  by  the  erroneous  idea  of 
appl3’ing  the  Hunterian  principles  in  the  treatment  of  aneurism  to  that 
of  wounded  arteries,  until  Guthrie,  by  his  practice  and  precepts,  and  by 
adducing  an  overwhelming  mass  of  proof  to  bear  on  this  important  ques¬ 
tion,  recalled  the  attention  of  the  Profession  to  the  proper  and  rational 
treatment  of  wounded  arteries. 

1.  The  principal  reason  in  favor  of  cutting  down  directly  upon  the 
wounded  part  of  the  injured  vessel.,  is  that  the  ligature  of  the  main  trunk 
at  a  distance  above  it  would  only  stop  the  direct  supply  of  blood  to  the 
limb,  but  would  not  interfere  with  the  indirect  or  anastomosing  circula¬ 
tion  :  this  finds  its  way  readily  into  that  portion  of  the  vessel  which  is 
below  the  ligature,  and  the  blood  carried  by  it  would  consequently 
continue  to  escape  b}^  tlie  distal  aperture  in  the  arteiy.  Thus,  though 
bright  arterial  blood  may  no  longer  jet  from  the  upper  part  of  the 
wound,  blood  which  has  become  of  a  dark  color  in  consequence  of  the 


^  “Principles  of  Surgery,”  vol.  i.  pp.  350,  390.  8vo.  edit. 


PRINCIPLES  OF  TREATMENT  BY  LIGATURE. 


245 


changes  to  which  it  is  subjected  in  its  passage  through  the  vascular  net- 
w'ork  of  the  limb,  will  continue  to  well  out  from  the  lower  aperture  in  the 
arteiy,  entailing  the  necessit}'  of  further  operative  procedure  to  restrain 
its  flow ;  and,  unless  this  be  done,  the  patient  will  die  of  hemorrhage  as 
surely,  though  perhaps  not  quite  so  speedily,  as  if  no  ligature  had  been 
applied.  Thus,  if  a  Surgeon  endeavor  to  arrest  the  flow  of  blood  from 
a  wound  of  the  ulnar  arteiy  near  the  palm  133^  ligaturing  the  brachial  in 
the  middle  of  the  arm,  and,  when  the  blood  bursts  forth  as  furiously  as 
ever,  appl3'  successive  ligatures  to  the  arteries  of  the  forearm  with  as 
little  success;  he  will  at  last,  by  the  continued  recurrence  of  hemorrhage, 
be  forced  to  adopt  the  simple  expedient  that  ought  to  have  been  had 
recourse  to  in  the  first  instance— ligaturing  the  vessel  at  the  point 
wounded,  and  thus  he  will  at  length  succeed  in  arresting  the  bleeding 
by  the  practice  which  he  should  at  first  have  adopted. 

Another  reason  for  the  practice  now  advocated  is,  that  in  some  cases 
the  Surgeon  cannot  possible  know  what  arterv  is  injured  unless  he  seek 
for  it  in  the  wound  itself.  A  large  artery  ma}^,  from  the  direction  of  the 
stab  and  the  impetuous  flow  of  blood  that  has  followed  it,  appear  to  be 
wounded,  when  in  realit}",  it  is  onl}"  a  minor  branch  that  has  been 
injured.  Thus,  for  instance,  in  hemorrhage  from  a  stab  in  the  axilla, 
which  proved  fatal,  notwithstanding  the  ligature  of  the  subclavian  arteiy 
for  supposed  wound  of  the  axillar3",  the  long  thoracic  was  found  to  be 
the  vessel  divided;  so  also  the  external  iliac  arteiy  has  been  ligatured 
for  supposed  wound  of  the  common  femoral,  when  in  reality  it  was  the 
external  pudic  that  was  injured. 

The  rule  of  cutting  down  on  the  injured  part  of  the  artery  applies  to 
all  cases  in  which  the  wound  is  still  open,  whatever  be  its  condition. 
However  deep,  inflamed,  and  slough}' the  wound;  however  ill-conditioned 
and  infiltrated  with  pus  or  blood  the  neighboring  parts  ma}'  be,  it  may 
be  stated  as  a  general  rule,  to  which,  however,  there  are  some  exceptions, 
especiall}'  in  wounds  of  the  palmer  arch,  or  of  the  secondaiy  branches  of 
the  carotid,  that  there  is  no  safety  to  the  patient  unless  the  artery  be 
cut  down  upon  and  tied  at  the  part  injured.  This  must  alwa3'S  be  done  at 
any  period  after  the  receipt  of  the  injuiy,  so  long  as  there  is  an  external 
wound  communicating  with  the  arteiy.  An  operation  of  this  kind  is 
often  attended  with  the  greatest  possible  difficult}',  not  only  owing  to 
the  hemorrhage  that  usually  accompanies  it  and  obscures  the  parts,  but 
also  in  consequence  of  the  inflamed,  infiltrated,  and  sloughy  condition  of 
the  tissues  in  the  wound.  In  order  to  moderate  the  hemorrhage,  tire 
pressure  of  an  assistant’s  finger  on  the  artery  high  up  in  the  limb  must 
not  be  trusted  to;  but  a  tourniquet  should  be  applied  so  as  completely 
to  arrest  the  circulation  through  the  limb,  and  thus  to  facilitate  the 
discovery  and  exposure  of  the  injured  vessel,  the  w'ound  being  dry.  A 
large  probe  should  then  be  passed  to  the  bottom  of  the  wound;  and, 
taking  this  as  the  centre,  a  free  incision  should  he  made  in  such  a  direc¬ 
tion  as  may  best  lay  open  the  cavity  with  the  least  injury  to  the  muscles 
and  other  soft  parts.  After  turning  out  any  coagula  contained  in  the 
wound,  and  clearing  it  as  well  as  possible,  the  injured  vessel  must  be 
sought  for.  The  situation  of  this  may  sometimes  be  ascertained  at  once 
by  the  gaping  of  the  cut  in  its  coats.  In  many  cases,  however,  it  is 
necessary  to  relax  the  pressure  upon  the  artery,  so  as  to  allow  a  jet  of 
blood  to  escape,  and  thus  indicate  the  position  of  the  aperture.  The 
ligature  may  then  be  applied  by  passing  an  aneurism-needle  under  the 
vessel,  if  it  be  partially  divided;  or,  if  it  be  completely  cut  across,  by 
drawing  forwards  the  end  and  ligaturing  it,  as  in  an  open  wound.  In 


246 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


doing  this,  care  must  be  taken  that  the  ligature  be  reall}'  applied  to  the 
vessel,  and  that  a  portion  of  the  sheath  infiltrated  with  blood,  or  thick¬ 
ened  by  adherent  coagulum,  be  not  mistaken  for  the  arteiy.  In  applying 
the  ligature  in  the  circumstances  here  indicated,  viz.,  in  a  wound  that  is 
sloughy  and  suppurating,  the  tissues  will  necessarily  in  a  great  degree 
have  lost  their  cohesion  and  firmness ;  and  although  the  arterial  tissue 
resists  the  disorganizing  infiuence  of  low  infiammatoiy  action  much 
longer  than  areolar  or  muscular  tissue,  3’et  it  will  also  have  become 
softened  and  less  resisting.  Hence  the  vessel  must  be  isolated  with 
gentleness  and  care,  and  the  ligature  veiy  carefully  tied — no  undue  force 
being  used.  The  ligature  will  usuall}-  separate  in  such  cases  several 
da3^s  before  the  ordinaiy  time.  The  incisions  down  to  the  wounded 
artery  should  generall}"  be  made  on  the  side  of  the  wound  itself,  and 
through  the  wound  in  the  soft  tissues  covering  it.  Guthrie,  however, 
advises  that,  in  those  cases  in  which  the  wound  passes  indirecth^  to  the 
principal  arteiy  from  the  back  or  outside  of  the  limb,  the  Surgeon  need 
not  follow  the  track  of  the  wound,  but  may  cut  down  on  the  vessel 
wliere  it  lies  nearest  the  surface;  then,  on  passing  a  probe  through  the 
wound,  the  spot  at  which  the  artery  has  probably"  been  injured  will  be 
pointed  out,  and  the  ligature  must  then  be  applied  in  the  wa}^  usual  in 
cases  of  primar}’  hemorrhage. 

In  'primary  hemorrage  from  wound  of  an  arteiy,  no  operation  should 
be  undertaken  unless  the  bleeding  be  actually  continuing.  If  the  bleed¬ 
ing  have  been  arrested,  however  furious  it  may  have  been,  the  Surgeon 
should  never,  unless  it  burst  forth  again,  search  for  the  wounded  vessel, 
nor  undertake  ain^  operation.  A  man  was  brought  to  the  University^ 
College  Hospital  with  a  deep  stab  in  the  groin,  directly^  in  the  course  of 
the  external  iliac  arteiy  ;  a  veiy  large  quantity'  of  arterial  blood  had 
been  lost,  but  the  hemorrhage  was  arrested  on  his  admission  by'  the  applica¬ 
tion  of  pressure,  etc.  F rom  the  great  and  sudden  loss  of  blood  it  was  sup¬ 
posed  that  the  external  iliac  had  been  punctured,  but  it  was  not  thought 
advisable  to  perform  any'  operation  unless  hemorrhage  recurred.  The 
bleeding  did  not  return,  the  wound  healing  without  anv  further  trouble. 
In  iiecondary  hemorrhage  the  case  is  diflferent.  There  the  Surgeon  must 
be  prepared  to  secure  the  vessel,  even  though  bleeding  have  for  the  time 
ceased. 

2.  The  second  great  principle  in  the  treatment  of  wounded  arteries  is, 
that  the  ligature  is  to  he  applied  to  both  ends  of  the  vessel,  if  it  he  com¬ 
pletely  cut  across ;  or  on  both  sides  of  the  aperture  in  it,  if  it  he  only  par¬ 
tially  divided. 

The  reason  for  this  rule  of  practice  is  founded  on  physiological  grounds 
as  well  as  on  practical  experience.  If  the  anastomoses  of  the  part  be 
very  free,  as  in  the  arteries  of  the  palm  or  forearm,  bleeding  may  con¬ 
tinue  from  the  distal  end,  uninterrupted  by'  the  ligature  on  the  proximal 
side  of  the  wound.  If  they'  be  less  free,  it  will  probably  issue  in  a  stream 
of  dark-looking  venous  blood  in  the  course  of  two  or  three  days.  After 
the  collateral  circulation  has  been  sutficiently'  established,  bright  scarlet 
blood  will  burst  forth  from  the  distal  aperture.  Experience  has  shown 
that  it  is  in  this  way^  that  secondary'  hemorrhage  from  wounded  arteries 
commonly^  occurs,  the  bleeding  coming  from  the  distal  and  not  from  the 
proximal  end  of  the  vessel. 

In  some  cases  the  distal  end  is  so  retracted  and  covered  in  by  sur¬ 
rounding  parts,  that  it  cannot  be  found  in  order  to  be  ligatured.  In 
the  circumstances,  the  best  effect  has  resulted  from  plugging  the  wound 


APPLICATION  OF  LIGATURE. 


247 


from  the  bottom  with  a  graduated  sponge-compress.  If  an  arterial 
branch  happen  to  be  divided  so  close  to  its  origin  that  it  cannot  be 
secured,  the  case  must  be  treated  as  one  of  puncture  of  the  main 
trunk,  which  must  be  ligatured  above  and  below  the  bleeding  orifice. 

Although  advocating  strongly  the  importance  of  the  distal  as  well  as 
the  proximal  ligature  in  all  cases  of  wounded  artery,  I  am  aware  that 
instances  are  on  record  in  which  the  proximal  ligature  alone,  even  at  a 
distance  from  the  wound,  has  proved  successful  in  arresting  the  hemor¬ 
rhage  :  but  I  cannot  do  otherwise  than  regard  those  cases  as  accidentally 
successful,  the  distal  end  having  been  better  plugged  than  usual  with 
coagulum  ;  and  I  am  strongly  of  opinion  that  the  rule  of  practice  should 
be  that  which  is  laid  down  by  John  Bell,  and  forcibly  illustrated  by 
Guthrie,  viz. :  That  both  ends  of  a  wounded  artery  be  sought  for,  and 
tied  in  the  wound  itself. 

Application  of  the  Ligaiure. — The  mode  of  application  of  the  ligature, 
and  the  kind  of  ligature  to  be  used,  vary  according  as,  1,  the  cut  end  of 
the  artery  has  to  be  tied  in  an  open  wound,  or  as,  2,  the  vessel  has  to  be 
secured  in  its  continuity. 

1.  When  the  divided  vessel  in  an  open  wound  has  to  be  tied,  as  after 
an  amputation,  the  mouth  of  the  artery  must  be  seized  and  drawn  for¬ 
wards  (Fig.  93).  For  this  purpose  a  tenaculum,  or  sharp  hook,  is  fre¬ 
quently  used,  and  in  many  cases 
answers  the  purpose  exceedingly 
well.  There  are,  however,  some 
objections  to  this  instrument  ; 
thus,  it  occasional!}’’  seizes  other 
tissues  with  the  artery,  and,  as 
it  draws  the  vessel  forwards  by 
perforating  its  coats,  it  has  hap¬ 
pened  that,  an  accidental  punc¬ 
ture  having  been  made  by  it  be¬ 
hind  the  part  to  which  the  ligature 
is  applied,  ulceration  of  the  vessel 
and  subsequent  fatal  hemorrhage 
have  ensued,  as  I  have  seen  in  one 
case.  The  most  convenient  in¬ 
strument  for  the  purpose  of  draw¬ 
ing  forward  the  artery,  and  one 
to  which  no  objection  whatever 
applies,  is  Liston’s  “  bull-dog  ” 
forceps.  These  have  been  con¬ 
veniently  modified  by  having  the 

blades  expanded  just  abov^e  the  points  (Fig.  94),  so  that  the  ligature  can 
be  slipped  over  the  end  of  an  artery  that  is  deeply  seated,  as  between 


Fig.  93. 


End  of  Artery  drawn  forwards.  Application  of 


Ligature. 


Fig.  94. 


bones  or  close  to  the  interosseus  membrane  of  the  leg — a  situation  in 
which  it  is  sometimes  troublesome  to  tie  a  vessel  by  any  other  means. 


248 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


In  some  cases  the  bleeding  point  may  be  so  situated,  that  the  ligature 
is  most  conveniently  passed  under  and  round  it  by  means  of  an  ordinary 
curved  needle. 

The  kind  of  ligature  used  must  vary  according  to  the  size  of  the  vessel. 
If  this  be  small,  fine  round  twine;  if  large,  dentist’s  silk,  or  compressed 
smooth  whip-cord,  should  be  employed.  The  latter  should  always  be 
used  in  ligaturing  the  main  artery  of  a  limb.  Before  being  used,  the 
material  should  be  well  waxed,  so  that  it  may  not  be  too  limp;  its 
strength  should  be  tested  by  knotting  it  with  a  jerk,  and,  if  found 
efficient,  it  may  be  cut  up  for  use  in  pieces  eighteen  inches  in  length.  In 
applying  the  ligature,  care  must  be  taken  that  it  be  put  well  beyond  the 
cut  end  of  the  artery,  that  it  clear  the  points  of  the  forceps,  and  that  it 

be  tied  tightly  in  a  reef-knot,  which  does 
Fig.  95.  not  slip  (Fig.  95).  One  end  of  the  ligature 

should  then  be  cut  off  about  a  quarter  of 

f  ^  from  the  knot,  and  the  other  left 

I  B  hanging  out  of  the  wound.  The  ligature 

y  (  1  B  secures  the  main  artery  should  have 

V  ^  ^  both  its  ends  knotted  together,  by  way  of 

distinctive  mark.  It  is  always  better  to 
A  Keef-knot.  leave  One  end  of  the  ligature ;  if  both  be 

cut  off,  tlie  noose  and  knot  left  are  apt  to 
become  enveloped  by  granulations  or  adhesive  matter,  and,  after  the 
healing  process  is  well  advanced,  or  perhaps  completed,  to  give  rise  to 
suppuration  in  and  re-opening  of  the  wound.  The  ligature  that  hangs 
out  of  the  wound  acts  as  a  seton,  giving  rise  to  a  track  of  suppuration 
along  its  course,  and  thus  so  far  preventing  union  of  the  wound  by  the 
first  intention.  The  end  of  the  artery  which  is  included  in,  and  which 
projects  bej^ond,  the  noose,  sloughs,  and  thus  acts  as  a  foreign  body  in 
the  wound.  When  the  artery  that  is  tied  is  small,  it  disintegrates  and 
breaks  down  in  the  discharges ;  when  it  is  large,  it  separates,  often 
attached  to  the  noose  of  the  ligature  when  that  has  ulcerated  through 
the  portion  of  the  vessel  that  has  been  tied.  These  inconveniences  are 
inseparable  from  the  use  of  the  ligature,  but  may  be  materially  lessened 
by  the  Surgeon  bringing  the  threads  out  at  the  innermost  angle  of  the 
wound,  and  thus  allowing  the  discharges  to  escape  at  the  most  depend¬ 
ent  part. 

2.  When  the  artery  has  to  be  ligatured  in  its  continuity^  but  at  the 
point  wounded,  it  must  be  exposed  by  as  careful  a  dissection  as  the 
state  of  the  parts  will  admit.  If  a  Surgeon  determine  to  apply  a  ligature 
at  a  distance  from  the  injury,  his  anatomical  knowledge  will  guide  him 
to  the  vessel.  This  is  usuallj"  done  by  cutting  through  the  tissues  in 
the  course  of  the  vessel;  Hargrave,  however,  recommends  that,  in  liga¬ 
turing  arteries,  the  incisions  should  not  be  made  parallel  to  the  course 
of  the  vessel,  but  in  an  oblique  or  transverse  direction  over  it ;  and  this 
suggestion  appears  to  me  to  be  deserving  of  attention  in  some  situations, 
more  particularly  in  the  ligature  of  the  branchial  at  the  bend  of  the  arm, 
or  of  the  carotid  at  the  root  of  the  neck.  The  Surgeon  is  usually  guided 
to  the  vessel  by  some  fixed  line  or  point,  at  the  edge  of  a  muscle,  which 
has  a  determined  and  constant  relation  to  the  artery.  Thus,  in  exposing 
the  brachial,  he  cuts  along  the  inner  border  of  the  biceps.  In  some 
cases,  however,  as  in  the  ligature  of  the  iliac  arteries,  no  such  certain 
anatomical  guide  exists,  and  then  an  imaginary  line  is  drawn  between 
two  fixed  points — as  the  umbilicus  and  the  centre  of  Poupart’s  ligament 


APPLICATION  OF  LIGATUKE. 


249 


— which  becomes  the  guide  to  the  course  of  the  vessel.  These  “direct¬ 
ing  lines”  should  be  carefully  studied  and  kept  in  mind. 

In  making  the  first  incision,  the  skin  should  be  put  on  the  stretch  by 
the  fingers  of  the  left  hand,  or  by  those  of  an  assistant.  If  the  artery  be 
superficial,  or  if  there  be  parts  of  importance  in  its  vicinity,  the  incision 
should  not  penetrate  deeper  than  the  skin.  But  if  the  vessel  be  deeply 
seated  and  no  parts  of  importance  intervene,  it  ma}'’  be  carried  at  once 
through  the  subcutaneous  areolar  tissue,  until  the  fascia  covering  the 
artery  is  exposed.  This  must  then  be  pinched  up  with  the  forceps,  and 
opened  by  the  edge  of  the  scalpel  laid  horizontally.  Through  this  open¬ 
ing  a  grooved  director  may  then  be  passed,  and  the  fascia  incised  on  it, 
without  risk  to  subjacent  parts.  The  sheath  of  the  vessel  is  now  exi)osed 
by  a  little  careful  dissection  ;  and  the  next  step  of  the  operation,  which 
consists  in  exposing  the  artery  and  se[)arating  it  from  its  accompanying 
vein,  is  one  of  great  delicacy.  This  is  done  by  pinching  up  the  sheath 
with  the  forceps  and  applying  the  knife  horizontally  (Fig.  96).  The 
point  should  never  be  used,  nor  the  blade  turned  downwards  against 
the  artery,  as  an  incautious  movement  or  the  mere  pulsation  of  the 
vessel  might  cause  it  to  be  wounded.  The  artery  having  thus  been 
exposed,  the  Surgeon  seizes  one  edge  of  the  sheath  with  the  forceps, 
and,  putting  it  on  the  stretch,  gently  separates  the  arteiy  from  its 


Fis:.  96. 


Exposure  and  Opening  of  the  Sheath. 


Fig.  97. 


Opening  in  the  Sheath 
Vessels  exposed. 


accompanying  vein  by  teasing  through  the  areolar  connections  with  the 
end  of  the  aneurism-needle,  or  with  a  director ;  being  careful  not  to 
expose  it  to  a  greater  extent  than  is  absolutely  necessary  for  the  passage 
of  the  ligature,  lest  subsequent  sloughing  of  the  vessel  ensue,  as  a 
consequence  of  the  destruction  of  the  vascular  connections  between  it 
and  the  sheath  (Fig.  97). 

In  opening  the  sheath,  care  should  be  taken  not  to  wound  any  small 
branch,  lest  the  collateral  supply  be  interfered  with,  and  danger  of  sec¬ 
ondary  hemorrhage  induced.  The  edge  in  the  opening  of  the  sheath 
being  held  tightly  in  the  forceps  so  as  to  be  rendered  tense  (Fig.  98), 
the  ligature  should  then  be  carefully  passed  between  the  vein  and 


250 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


Fig.  98. 


Passage  of  th-e  Needle  and  Ligature. 


artery,  care  being  taken  to  include 
only  the  latter,  and  especially  not 
to  transfix  and  include  a  portion  of 
the  vein ;  an  incident  that  often 
terminates  fatall}"  by  phlebitis  or 
gangrene.  So  also  the  Surgeon 
must  be  on  his  guard  not  to  mis¬ 
take  any  contiguous  nerve  for  the 
artery,  as  has  happened  to  the  most 
experienced  operators ;  and  also 
to  avoid  transfixing  and  tying  a 
portion  of  the  thickened  sheath  in¬ 
stead  of  the  vessel,  as  I  have  known 
happen  to  a  most  excellent  Sur¬ 
geon. 


The  Tying  of  the  Artery  and  the  consequent  Division  o  f  the  Internal 
and  Middle  Coats  should  be  done  evenl}^,  smoothl}',  and  completely, 
so  as  to  leave  a  w'ound  that  readily  takes  on  the  adhesive  inflammation. 
This  is  best  done  by  a  small  round  ligature  applied  with  such  a  degree 
of  force  that  the  Surgeon  feels  the  coats  give  way  under  his  finger.  In 
this  a  subcutaneous  section,  as  it  were,  is  effected ;  and  this,  like  all 
similar  wonnds,  takes  on  adhesive  action.  The  adhesion  between  the 
coats  is  much  facilitated  by  the  pressure  of  the  ligature,  which  acts  as  a 
support  to  the  vessel. 

The  best  material  for  ligature^  when  applied  to  the  continuity  of  an 
artery,  is  dentist’s  silk  or  compressed  whipcord,  w’ell  waxed,  and  tied  in 
a  reef-knot,  as  represented  in  fig.  95.  Much  ingenuit^^  has  been  expended 
in  devising  instruments  for  passing  it  under  the  artery.  In  the  majority 
of  cases  the  common  aneurism-needle — well  ground  down,  but  rounded 
at  its  extremity — is  all  that  is  required.  Occasionally  it  ma}^  be  advan¬ 
tageous  to  use  a  needle  with  a  small  curve.  Many  ingenious  contri¬ 
vances  have  been  devised  by  Trant,  Weiss,  Coxeter,  and  others,  for 
seizinor  and  drawing  forward  the  noose  from  the  bottom  of  the  wound. 
After  the  ligature  has  been  passed  under  the  vessel  it  should  be  tied 
tightl}^  with  a  reef-knot,  and  both  its  ends  left  hanging  out  of  the 
w'ound.  The  limb  should  then  be  elevated  and  be  tightly  covered  with  a 
piece  of  flannel,  or  of  cotton-wadding;  care  being  taken  not  to  apply 
pressure  of  an}’’  kind. 

Modifications  of  the  Ligature. — With  the  view  of  diminishing  or 
removing  the  various  inconveniences,  real  or  supposed,  that  result 
from  the  use  of  the  ligatuure,  and  especially  with  the  object  of  pro¬ 
moting  union  of  the  wound  by  the  first  intention,  four  methods  have 
been  employed  by  Surgeons:  1,  The  use  of  temporaiy  ligatures;  2, 
Cutting  the  ends  off  close  to  the  knots;  3,  The  use  of  wire  to  tie  the 
artery ;  and  4,  The  employment  of  materials  for  the  ligature  that  might 
be  absorbed  in  the  wound. 

1.  The  use  of  the  Temporary  Ligature  in  one  of  its  modifications 
has  alread}^  been  attended  to.  This  subject  full^'  occupied  the  attention 
of  Surgeons  in  this  countiy  nearl}^  half  a  centur^^  ago,  and  has  now  in 
a  great  measure  become  matter  of  history,  for  the  study  of  which  I 
must  refer  to  the  writings  of  Jones,  Travers,  Yelpeau,  and  others.  I 
may,  however,  state,  that  the  general  result  of  the  experiments  made 
and  the  experience  derived  on  this  subject,  is  the  following. 

Jones  found  that,  on  cutting  through  the  internal  and  middle  coats  of 
the  carotid  artery  of  a  horse  at  three  or  four  different  points,  with  as 


MODIFICATIONS  OF  LIGATURE. 


251' 


many  ligatures,  and  then  immediately  removing  them,  an  effusion  of 
lymph  occurred  by  which  the  artery  w\as  plugged  up. 

These  observations  were  not  confirmed  by  other  experimenters,  such 
as  Hodgson,  Travers,  and  Dalr3unple. 

But  Travers  found  that,  if  the  ligature  were  left  in  for  several  hours,  or 
even  for  one  hour,  and  then  removed,  obliteration  of  the  artery  ensued. 

Roberts  applied  a  ligature  to  the  femoral  artery  for  popliteal  aneu¬ 
rism,  and,  on  removing  it  after  24  hours,  found  the  arteiy  closed  ;  and 
Travers  ligatured  the  brachial  artery  of  a  man,  and,  on  removing  the 
ligature  at  the  end  of  50  hours,  obtained  an  equall}^  successful  result. 
Their  example  w'as  followed  by  Scarpa  and  Paletta. 

Notwithstanding  these  favorable  results,  the  failure  of  the  method  in 
the  hands  of  Astley  Cooper,  of  Hutchinson,  of  Bedard,  of  Travers  him¬ 
self,  and  the  observation  of  Yacca,  that,  if  the  ligature  be  left  on  the 
artery  long  enough  to  cause  its  obliteration,  the  section  of  the  vessel  is 
effected  sooner  or  later,  caused  the  use  of  the  temporary  ligature  to  be 
discontinued  in  surgical  practice,  even  by  those  who  at  one  time  had 
most  strongly  advocated  it. 

2.  The  practice  of  Gutting  off  the  Ends  of  the  Ligature  close  to  the 
knot,  has  been  adopted  b^’  many  Surgeons  in  the  hope  that  it  might 
either  be  absorbed,  or,  at  least,  that  the  irritation  of  the  wound  resulting 
from  the  dependent  threads  might  be  prevented.  Tliis  practice  was  at 
one  time  much  avocated  by  Lawrence ;  but,  thougli  emplo^^ed  by  him  at 
St.  Bartholomew’s  Hospital  in  many  cases  of  amputation,  excision  of 
the  breast,  and  removal  of  the  testicles,  it  w^as  relinquished  b^^  him  for 
more  than  thirty  3'ears  before  his  death.  He  found  that  the  noose  and 
knot  of  the  finest  silk  thread,  such  as  is  used  for  fish-lines,  did  not  weigh 
more  than  the  one-fortieth  of  a  grain,  when  cut  close  to  the  vessel. 
But,  although  some  success  attended  the  earlier  use  of  the  method,  it 
W’as  soon  found  that  even  this  small  quantit3',  together  with  the  tied  end 
of  the  vessel,  set  up  irritation,  gave  rise  to  abscess,  and  w’as  injurious : 
hence  its  abandonment  in  all  cases  in  which  the  wound  is  closed  with  the 
view  to  speedy  union.  When  the  w^ound  is  left  open  to  granulate.  Sur¬ 
geons  commonl3'  adopt  this  plan  of  treatment. 

3.  The  use  of  Wire  Ligatures  is  altogether  of  American  origin.  It 
originated  with  Ph3’sick  and  Levert  of  Alabama,  who  performed  several 
experiments  with  threads  of  gold,  silver,  platinum,  and  lead.  They 
found  that  with  these  the  arteries  of  animals  could  be  successfull3^  tied, 
and  that,  the  material  of  the  ligature  being  unirritating,  no  evil  from 
suppuration  ensued.  Y^'lien  the  ends  of  the  ligature  were  cut  off  close 
to  the  vessel,  it  w^as  found  that  the  small  metallic  noose  became  imbedded 
in  a  cellular  capsule.  For  some  reason,  this  means  fell  into  disuse,  until 
it  was  revived  ly  Marion  Sims.  At  his  suggestion  I  tried  it  in  several 
cases  of  amputation  and  other  surgical  operations,  but  have  long  since 
abandoned  it,  as  I  found  great  inconveniences  resulting  from  its  use. 
If  the  ends  of  the  wire  w^ere  left  out  of  the  wound,  the  noose  became 
imbedded  in  a  mass  of  plastic  matter,  did  not  separate,  and,  after  several 
w'eeks,  required  considerable  force  to  detach  and  disconnect  it.  If  the 
ends  were  cut  short,  the  sides  of  the  wound  healed  over  them, — they 
became  encapsuled,  but  were  by'  no  means  innocuous ;  in  some  cases 
giving  rise  to  severe  neuralgia  of  the  stump  by  pressure  on  and  irritation 
of  neighboring  nerves ;  in  others,  after  some  weeks,  causing  localized 
circumscribed  abscesses  to  form. 

4.  The  employ’ment  of  Ligatures  made  of  Materials  that  admit  of 
Absorption  in  the  w'ound  has  been  a  favorite  idea  with  many  Surgeons, 


252 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


and  is  one  on  which  much  experimental  ingenuity  has  at  various  times 
been  expended  ;  for  the  idea  is  a  captivating  one,  and  if  it  could  be 
safel^^,  certainly,  and  successfully  carried  out  in  practice,  it  would  un- 
doubtedlj''  remove  one  of  the  obstacles  to  the  union  of  wounds  by  direct 
adhesion.  With  this  view  it  was  proposed  to  substitute  ligatures  made 
of  animal  substances  for  the  ordinary  threads  made  of  hemp.  Silk 
thread  was  used  by  Lawrence  in  1815,  and  at  first  with  success,  union 
of  the  wound  taking  place  in  four  to  six  days,  without  suppuration. 
But  other  Surgeons  failed  in  this,  and  Lawrence  himself  was  soon  com¬ 
pelled  to  give  it  up  from  want  of  good  results  in  his  subsequent  cases. 
Wardrop  substituted  the  gut  of  the  silk-worm  made  into  a  fine  cord, 
but  with  equally  unsatisfactory  results. 

Catgut  was  used  by  Sir  Astley  Cooper  as  a  material  that  was  more 
likely  to  dissolve  or  to  be  absorbed  than  silk  in  any  shape.  The  first 
cases  ill  which  it  was  employed  as  a  ligature  were  full  of  promise.  In 
one,  a  patient  of  eighty,  the  wound  healed  in  four  days,  and  in  another 
in  twenty,  and  in  neither  did  the  noose  of  the  ligature  reappear. 
Whether  it  was  absorbed  or  encapsuled  does  not  clearly  appear.  But 
other  Surgeons  failed  to  imitate  this  success  ;  the  catgut  was  found  to 
be  too  weak,  and  the  distinguished  author  of  the  practice  could  not  him¬ 
self  maintain  his  first  success  with  it,  and  eventually  fell  back  on  the 
ordinary  hempen  thread. 

Strips  of  deer-skin  were  used  by  Jameson,  of  Philadelphia,  and  other 
American  Surgeons  about  the  same  time,  probably  in  1814,  before  Law¬ 
rence’s  or  Cooper’s  experiments.  They  were  found  to  answer  better  than 
either  silk  or  catgut,  being  stronger,  more  elastic,  and  more  readil}’’ , 
soluble.  These,  however,  also  fell  into  disuse,  for  what  reason  does  not 
clearly  appear. 

The  idea  of  the  employment  of  ligatures  made  of  animal  substances, 
that  would  admit  of  absorption,  and  thus  allow  the  wound  to  be  imme¬ 
diately  closed  over  the  noose,  so  as  in  fact  not  to  act  as  foreign  bodies 
in  the  wound  or  as  agents  of  suppuration,  still  occasionally  presented 
itself  to  the  minds  of  Surgeons  ;  and,  amongst  others,  Yelpeau  speaks 
of  it  with  favor,  admitting,  however,  that  their  precise  nature  and  form 
have  to  be  determined.  Of  late  the  use  of  catgut  has  been  revived 
b}^  Lister,  in  connection  with  his  “Antiseptic  Method”  of  dressing 
wounds.  He  uses  the  catgut  soaked  in  carbolized  oil,  and  has  reported 
favorably  of  its  employment.  But  more  widely  extended  experiments 
are  required  to  determine  its  real  value.  For  it  is  impossible  not  to  be 
struck  by  the  remarkable  fact  that,  in  all  the  various  attempts  at  the 
modification  of  the  ligature,  and  the  substitution  of  unirritating  or 
absorbable  materials,  that  have  been  made  during  the  last  fifty  3^ears, 
tLe  good  results  that  have  so  often,  and  in  such  varying  circum¬ 
stances,  been  obtained  by  the  inventors  of  a  new  method,  have  failed  to 
be  secured  by  other  Surgeons,  or  even  maintained  b}^  themselves.  In¬ 
creased  experience  in  the  use  of  the  carbolized  catgut  ligature  has  done 
much  to  strengthen  m}^  confidence  in  it.  I  have  used  and  seen  it  used  in 
several  cases  of  liofature  of  arteries  with  much  success.  When  the  ends 
are  cut  short,  the  wound  if  treated  antisepticall^"  may  close  over  them  with¬ 
out  a  vestige  of  pus,  and  the  ligature  disappears,  the  artery  being  divided 
b}^  a  kind  of  septum  which  stretches  across  it  at  the  part  deligated. 

Other  modifications  of  the  ligature  have  been  devised  by  Surgeons  in 
order  to  prevent  the  dangerous  and  troublesome  consequences  arising 
from  the  suppuration  occasioned  by  it.  Some,  instead  of  bringing  the 
ends  out  of  the  w'ouiid,  after  having  tied  the  various  arteries  in  the  usual 


EFFECTS  OF  LIGATURE. 


253 


wa}^,  cut  off  one  end  of  each  ligature,  and  then  draw  the  remaining  one  out 
through  a  separate  puncture  in  the  skin.  Other  Surgeons,  again,  have 
contented  themselves  with  simply  passing  the  ligature  round  tlie  artery, 
raising  tlie  vessel  in  the  loop  of  the  thread,  which  is  not  tied,  and  bring¬ 
ing  both  ends  out  through  a  puncture  made  in  the  skin,  where  the}^  are 
firmly  fixed,  so  that  the  vessel  is  compressed  by  the  loop,  not  tied  in  it. 
The  ligature  is  then  withdrawn,  at  the  expiration  of  two  or  three  days. 

These  methods  appear  to  me  to  have  little  to  recommend  them.  The 
first  complicates  rather  than  simplifies  the  operation  ;  and  at  each  liga¬ 
tured  point,  a  tendency  to  ulceration  might  easily  be  established.  The 
second  method  has  the  disadvantage  of  being  unsafe.  If  the  loop  be 
drawn  up  tightly,  it  will  cut  through  the  vessel  as  if  it  had  been  tied. 
If  it  be  left  slack,  there  will  certainly  be  a  tendency  to  secondary 
hemorrhage.  • 

Effectn  of  Ligature. — The  immediate  effects  on  an  artery  of  the  appli¬ 
cation  of  a  firm  round  ligature  with  a  proper  degree  of  force,  are  the 
division  of  the  internal  and  middle  coats  of  the  vessel,  and  the  con¬ 
striction  of  its  outer  one.  If  we  examine  the  ligatured  vessel  a  few  da3^s 
after  it  has  been  tied,  we  find  that  the  coats  are  contracted;  that  there 
is  an  internal  p3’ramidal  coagulum,  composed  of  plastic  matter  at  its 
base,  and  fibrinous  clot  towards  its  appex  (Fig.  99) ;  and  that  the  liga¬ 
tured  portion  of  the  vessel  is  surrounded  by  a  quantity  of  13'mph.  If 
the  arteiy  be  examined  at  a  still  later  period  than  this — at  the  end  of 
two  or  three  months,  for  instance — it  will  be  found  to  be  converted 
into  a  fibro-cellular  cord  as  high  as  the  first  collateral  branch  above 

_  KJ 

the  ligature  (Fig.  100).  Now  these  are  analogous  appearances  to  those 


Femoral  Artery,  flfty-six  hours 
after  Amputation. 


Brachial  Artery,  ten  days  after 
Amputation. 


Fig.  101. 


Femoral  Artery,  six  weeks 
after  Amputation. 


met  with  in  an  artery  that  has  been  cut  across  and  occluded  without  the 
application  of  a  ligature ;  and  are  evidentl3^  the  result  of  inflammation 
of  the  vessel.  The  question  arises,  how  this  inflammation  is  set  up  when  a 
ligature  is  applied.  Is  it  by  the  pressure  of  the  noose,  or  b3^  the  coats 
of  the  artery  ?  That  it  is  not  the  mere  pressure  of  the  ligature  that 
excites  the  occluding  inflammation,  is  evident  from  the  experiments  of 
Jones  and  of  Travers,  who  found  that,  if  the  ligature  were  removed 
shortly  after  its  application,  sufficient  inflammator3^  action  had  been 
excited  in  the  coats  of  the  artery  to  lead  to  its  complete  occlusion.  And 
though  an3"  inflammation  set  up  in  the  external  coat  may  cause  an  effu- 


254 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


sion  of  lymph  inside  the  vessel,  yet  that  which  is  required  to  repair  the 
breacli  occasioned  by  the  division  of  the  internal  and  middle  coats,  is 
the  principal  source  of  the  plastic  deposit.  The  changes  that  take  place 
in  the  vessel  after  the  application  of  a  ligature  require,  however,  to  be 
more  carefully  studied. 

The  Formation  of  the  Internal  Goagulum  in  the  proximal  end  is  the 
most  important  part  of  the  process.  For  the  first  four-and-twenty  hours 
after  the  application  of  the  ligature  there  is  little,  if  anj^,  appearance  of 
this.  Usually  about  this  time,  if  opportunit}^  offer  to  examine  an  artery 
in  the  human  subject,  it  will  be  found  that  a  small  nodule  of  lymph,  of 
a  3’ellowish  or  buff  color,  has  been  deposited  in  the  bottom  of  the  cul- 
de-sac  that  is  formed  b}^  the  retraction  and  contraction  of  the  cut  ends 
of  the  inner  and  middle  coats,  so  as  to  close  up  the  extremity  of  the 
arteiy.  About  the  second  or  t4iird  day,  this  coagulum  will  be  found  to 
have  assumed  a  conical  shape  (Fig.  99),  the  base  being  made  up  of 
decolorized  fibrine  and  exudation-matter,  firmly'  adherent  to  the  lower 
end  of  the  artery;  the  middle  and  terminal  portions  of  the  coagulum, 
composed  of  fibrinous  clot,  and  of  a  dark  purple  or  maroon  color,  lie 
loose  and  floating  in  the  artery,  extending  up  as  high  as  the  first  col¬ 
lateral  branch.  About  the  tentli  da3^,  the  inflamed  end  of  the  vessel  will 
be  found  to  be  tightly  and  firml3'  contracted  upon  the  inclosed  plug 
(Fig.  100),  the  dark-colored  portions  of  which  now  begin  to  undergo  a 
process  of  absorption.  Between  this  period  and  the  sixth  week,  the  con¬ 
traction  of  the  vessel  and  the  absorption  of  the  free  part  of  the  plug  go 
on  simultaneousl3^  (Fig.  101),  the  interior  of  the  arteiy  becoming  darkly 
stained  by  imbibition  of  the  coloring  matter  of  the  coagulum.  Lastly, 
the  plastic  base  of  the  plug  becomes  incorporated  with  the  contiguous  arte¬ 
rial  coats,  and  undergoes  eventual  transformation  into  fibro-cellular  tissue. 

In  some  cases  (Fig.  102),  there  is  an  imperfect  formation  of  the  in¬ 
ternal  plug,  or  even  total  absence  of  it,  and  not  unfrequently  secondary 

hemorrhage  occurs  as  a  con¬ 
sequence.  This  condition 
may  arise  either  from  want 
of  plasticity  in  the  blood, 
from  an  absence  of  due  ad¬ 
hesive  inflammation,  or  from 
the  coats  not  having  been 
properly  cut  through.  In 
other  cases,  in  consequence 
of  suppurative  action  being 
set  up  in  the  artery,  a  kind 
of  disintegration  or  lique¬ 
faction  of  the  plug  takes 
place  after  it  has  been 
formed.  This  I  have  seen 
happen  in  a  case  of  ligature 
of  the  carotid  artery,  in 
which  death  occurred  from 
visceral  disease  ten  weeks 
after  the  operation  ;  and  in 
the  femoral,  in  cases  of 
P3'aemia  (Fig.  103).  In  the 
distal  cul-de-sac  of  the  liga¬ 
tured  artery  I  have  never 
seen  any  veiy  distinct  coagu¬ 
lum  formed,  either  in  the 


Fig.  102. 


Partial  Absorption  of 
Coagulum  iu  Femoral, 
fourteen  days  after  Am¬ 
putation. 


Fig.  103. 


Femoral  Arteries,  ten 
after  Amputation  of  T 
Death  from  Pyaemia. 


ACUPRESSURE. 


255 


human  subject  or  in  dogs  on  which  I  have  experimented,  hut  merely 
small  detached  fragments  of  coagula  and  some  plastic  effusion. 

The  changes  that  take  place  in  the  External  Coat  are  most  important. 
After  the  external  and  middle  coats  have  been  cut  through  by  the  liga¬ 
ture,  the  external  would  not  be  able  to  resist  the  impulse  of  the  blood, 
were  it  not  strengthened  and  consolidated  by  the  adhesive  inflammation. 
The  necessary  inflammation  is  occasioned  partly  by  the  dissection 
required  to  expose  the  vessels,  and  partly  by  the  pressure  and  irritation 
of  the  ligature.  Lymph  is  thrown  out  between  the  vessel  and  its  sheath, 
matting  together  these  parts,  and  often  enveloping  the  noose  and  knot 
in  an  ovoid  mass.  Progressively  with  the  effusion  of  13’mph  and  conse¬ 
quent  strengthening  of  the  coats,  the  pressure  of  the  noose  causes 
gradual  sloughing  and  ulceration  of  the  part  included  in  it.  The  mode 
in  which  the  noose  ulcerates  its  wa}'^  through  the  external  coat  is  of  much 
importance,  as  on  this  depends  in  a  great  measure  the  success  of  the 
ligature.  There  are  two  sources  of  danger  in  connection  with  this  pro¬ 
cess  ;  either  the  sloughing  may  be  too  extensive,  or  the  ulceration 
through  the  artery  may  take  place  before  the  adhesive  plug  is  properly 
and  firmly  formed. 

The  chance  of  the  sloughing  being  too  extensive,  principall}’’  arises 
from  the  arteiy  being  isolated  and  separated  from  its  sheath  to  too  great 
an  extent  during  the  dissection  required  to  expose  it,  and  its  nutrient 
vessels  being  consequent!}"  divided  in  great  numbers,  so  as  to  deprive 
that  portion  of  the  coats  of  the  vessel  of  its  vascular  supply  ;  hence  the 
danger  of  passing  a  spatula,  large  probe,  or  the  handle  of  a  scalpel  under 
the  artery,  and  also  of  applying  several  ligatures.  Premature  ulceration 
of  the  vessel  may  occur,  either  from  the  patient’s  constitution  being  too 
debilitated  to  admit  of  health}’  reparative  action,  or  from  excessive  dege¬ 
neration  of  the  artery  at  the  point  ligatured. 

So  soon  as  the  ligature  has  ulcerated  through  that  portion  of  the  artery 
which  is  included  in  its  noose,  it  becomes  loosened  and  separates ;  fre¬ 
quently  being  thrown  off  with  the  discharges,  or  becoming  detached  on 
the  slightest  traction.  The  period  of  the  separation  of  the  ligature  de¬ 
pends  upon  the  size  of  the  artery  and  the  thickness  of  its  coats.  From 
the  radial  or  ulnar  arteries,  it  is  usually  detached  by  the  eighth  day  ;  from 
the  femoral,  iliac,  or  subclavian,  about  the  sixteenth  or  twentieth  day. 
In  some  cases  the  ligature  will  continue  attached  for  a  much  longer 
period  than  this,  owing  to  the  inclusion  within  its  noose  of  a  bit  of  fascia, 
nerve,  or  muscular  substance.  In  order  to  hasten  the  separation  in  these 
cases,  moderate  traction  and  occasional  twisting  of  the  ligature  may  be 
practised. 

8.  Acupressure. — By  Acupressure  is  meant  the  occlusion  of  an 
artery  by  the  pressure  of  a  needle  in  such  a  way  as  to  arrest  the  circu¬ 
lation  through  or  the  hemorrhage  from  it.  This  method  of  treatment 
was  introduced  into  surgical  practice  by  the  late  Sir  James  Simpson  as 
a  substitute  for  the  ligature.  Acupressure  may  be  applied  in  several 
different  ways.  There  are  four  principal  methods. 

The  firat  method  is  carried  out  in  the  following  way,  which  I  give  as 
nearly  as  possible  in  Sir  James  Simpson’s  own  words.  The  Surgeon 
places  the  tip  of  the  fore-finger  of  his  left  hand  upon  the  bleeding  mouth 
of  the  artery  which  he  intends  to  compress  and  close  ;  holding  the  needle 
in  his  right  hand,  he  passes  it  through  the  cutaneous  surface  of  the  flap, 
and  pushes  it  inwards  till  its  point  projects  out  to  the  extent  of  a  few 
lines  on  the  raw  surface  of  the  wound,  a  little  to  the  right  of,  and  anterior 
to,  his  finger-tip  ;  he  then,  by  the  action  of  his  right  hand  upon  the  head 


256 


AKREST  OF  ARTERIAL  HEMORRHAGE. 


of  the  needle,  turns  and  directs  its  sharp  extremity  so  that  it  makes  a 
bridge  as  it  were  across  the  site  of  the  tube  of  the  bleeding  artery,  im- 
mediatelj’  in  front  of  the  point  of  the  finger  with  which  he  is  shutting 
up  its  orifice ;  he  next,  either  with  tins  same  fore-finger  of  the  left  hand, 
or  with  the  side  of  the  extremity  of  the  needle  itself,  compresses  the 
locality  of  the  bleeding  arterial  orifice  and  tube,  and  then  pushes  on  the 
needle  with  his  right  hand,  so  as  to  make  it  re-enter  the  surface  of  the 
wound  a  little  to  the  left  side  of  the  artery  ;  and,  lastly,  b}^  pressing 
the  needle  farther  on  in  this  direction,  its  point  re-emerges  through  the 
cutaneous  surface  of  the  flap — the  site  of  the  tube  of  the  bleeding  artery 
being  in  this  way  left  pinned  down  in  a  compressed  state  by  the  arc  or 
bridge  of  steel  that  is  passed  over  it.  The  needle  thus  passes  first 
through  and  from  the  skin  of  the  flap  inwards  to  the  raw  surface  of  the 
wound,  and,  after  bridging  over  the  site  of  the  artery,  it  passes  secondly 
from  the  raw  surface  of  the  wound  outwards  again  to  and  through 
the  skin.  Sometimes  the  needle  will  be  best  passed  b}^  the  aid  of  the 
eye  alone,  and  without  guiding  its  course  by  the  finger-tip  applied  to  the 
bleeding  orifice.  It  compresses  not  the  arterial  tube  alone,  but  the 
structures  also  placed  over  and  around  the  site  of  the  tube.  When  the 
needle  is  completely  adjusted,  all  of  it  that  is  seen,  and  that  not  neces¬ 
sarily  so,  on  the  surface  of  the  raw  wound,  is  the  small  portion  of  it 
passing  over  the  site  of  the  artery  (Fig.  104)  ;  while  externally,  upon 


the  cutaneous  surface  of  the  flap,  we  have  remaining  exposed  more  or 
less  of  its  two  extremities,  namely,  its  point  and  its  head  (Fig.  105). 
The  rest  of  it  is  hidden  in  the  structures  of  the  flap  or  side  of  the  wound. 
The  degree  of  pressure  required  to  close  effectually  the  tube  of  an  artery 
is  certainly  much  less  than  Surgeons  generally  imagine;  but  in  the  above 
proceeding  the  amount  of  pressure  can  be  regulated  and  increased  when 
required,  by  the  acuteness  of  the  angle  at  which  the  needle  is  introduced 
and  again  passed  out — the  cutaneous  and  other  structures  of  the  flap 
serving  as  the  resisting  medium  against  which  the  needle  compresses 
the  arterial  tube. 

The  second  method  of  acupressure  consists  in  taking  a  short  sewing 
needle  with  a  piece  of  twisted  iron  wire  attached,  for  the  purpose  of 
withdrawing  it  when  necessary.  This 

is  dipped  down  into  the  soft  tissues  on  Fig.  106. 

one  side  of  the  artery ;  then  bridged 
over  the  vessel ;  then  dipped  down  again 
into  the  soft  structures  on  the  other 
side  of  the  vessel  (Fig.  106).  In  doing 
this,  care  must  be  taken  to  press  the 
end  of  the  needle  down  upon  the  bleed¬ 
ing  trunk  or  tube  of  the  artery  with  suf¬ 
ficient  force. 

The  third  method  is  the  one  that  is  Acupressure,  second  Method. 


ACUPRESSURE  AND  LIGATURE  COMPARED. 


257 


likel}^  to  be  most  frequently  followed,  and  is  upon  the  whole  the  most 
practical  and  the  best.  It  consists  in  compressing  the  arteiy  between  the 
needle  threaded  with  a  piece  of  twisted  iron  wire,  passed  below  or  behind 
it,  and  a  loop  of  inelastic  iron  wire  passed  over  or  above  it.  The  needle 
is  passed  as  in  the  last  cases,  but  on  the  opposite  side  of  the  arteiy.  The 
loop  of  iron  wire  is  thrown  over  the  point  of  the  needle  ;  it  is  then  passed 
across  the  arteiy,  drawn  tight  so  as  to  compress  the  vessel,  and  secured 
by  a  half  twist  round  the  eye  end  of  the  needle  (Fig.  107).  In  order  to 
remove  this  apparatus,  all  the  Surgeon  has  to  do  is  to  pull  the  twisted 
wire  with  which  the  needle  is  threaded  ;  this,  in  withdrawing  the  needle, 
liberates  the  loop,  which  may  then  easily  be  removed. 


Fig.  107.  Fig.  108. 


Acupressure.  Third  Method.  Acupressure.  Fourth  Method. 


The  fourth  method  consists  in  dipping  the  needle  into  the  tissues 
close  to  the  artery,  then  making  a  turn  with  the  point,  and  pushing  this 
into  the  soft  part  beyond,  so  as  to  fix  it  there,  and  thus  to  compress 
the  artery  (Fig.  108). 

The  Condition  of  the  Artery  after  having  been  subjected  to  acupres¬ 
sure  has  still  to  be  determined.  Does  the  pressure  of  the  needle  divide, 
as  the  ligature  does,  the  internal  and  middle  coats  ?  or  does  it  merely 
cause  them  to  adhere  b}"  direct  compression  ?  In  all  probability  the 
latter  result  is  the  onl}-  one  obtained  ;  a  coagulum  forming  b}'  the  stasis 
of  the  blood  between  the  point  compressed  and  the  nearest  collateral 
branch.  This  point  is  one  of  importance  ;  for  there  can  be  little  doubt 
that  one  of  the  safesiuards  after  the  ligature  is  this  division  of  the 
inner  coats  of  the  artery,  the  consequence  of  which  is  the  effusion  of 
a  plastic  plug  within  the  vessel,  by  which  it  is  more  effectually  sealed 
than  it  can  be  by  mere  cohesion  of  its  sides  and  the  formation  of  a 
blood-coagulum. 

The  time  during  which  the  needle  should  be  left  in  will  vary  with  the 
size  of  the  artery.  As  a  general  rule,  it  should  be  from  thirty  to  sixty 
hours  according  to  the  size  of  the  vessel.  The  needle  must  not  be 
left  in  too  long,  lest  irritation  be  set  up,  and  ulceration  induced  along 
its  track. 

Acupressure  and  Ligature  compared. — That  arterial  hemorrhage  may 
be  effectually  controlled  b}^  acupressure  in  many  cases,  is  undoubted. 
This  fact  has  long  been  familiar  to  Surgeons  in  the  operation  for  hare¬ 
lip,  in  which  the  bleeding  from  the  coronary  artery  is  restrained  b}"  the 
pin  that  is  passed  across  to  unite  the  opposite  sides  of  the  cleft,  and  it 
has  of  late  years  been  abundantly  proved  in  the  case  of  the  largest  ar¬ 
teries  divided  in  amputations.  But,  though  by  means  of  acupressure 
arterial  hemorrhage  may  undoubtedly  be  controlled,  the  real  question 
which  has  still  to  be  answered  is,  whether  we  are  justified  in  substi¬ 
tuting  this  means  for  the  ligature  in  surgical  practice.  When  we  re¬ 
flect  on  the  ease  and  certainty  with  which  the  most  furious  hemorrhage 
VOL.  I. — 17 


258 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


from  the  largest  artery  can  be  at  once  and  permanently  arrested,  by 
the  tying  of  the  mouth  of  the  bleeding  vessel  ^ith  a  silken  thread — the 
inestimable  advantage  'which  tlie  ligature  has  been  and  is  to  Surgeons, 
in  enabling  them  to  carry  the  knife  with  safety  into  regions  where  its 
pi’esence  would  be  fatal  but  for  this  means — we  should  not  lightlj*, 
and  on  insufficient  evidence,  throw  aside  the  means  of  such  tried  utility 
for  one  that  is  of  more  doubtful  value.  And  few  practical  Surgeons 
will  probably  discard  the  thread  for  the  needle  in  the  arrest  of  arterial 
hemorrhage,  unless  the  latter  can  be  proved  to  be  more  certain  and 
more  safe  than  the  former. 

Sir  James  Simpson,  who  pressed  the  subject  of  acupressure  upon 
the  attention  of  Surgeons  with  an  amount  of  zeal,  of  learning,  and  of 
experimental  research,  which  is  trulj-  to  be  admired,  advanced  a  variety 
of  arguments  in  favor  of  arresting  arterial  hemorrhage  by  the  needle 
rather  than  by  the  ligature.  These  may  briefly  be  summed  uj)  as 
follows : — 

The  great  object  of  every  Surgeon  is  to  heal  operation-wounds  by  the 
first  intention. 

A  serious  and  fatal  obstacle  to  this  method  of  healing  is  the  use  of 
the  ligature. 

The  ligature  acts  injuriouslj"  in  two  ways  :  1,  each  thread  acts  as  a 
setdn  and  sets  up  a  line  of  suppuration  along  its  track ;  and  2,  the  cut 
end  of  the  artery  included  in  and  projected  beyond  its  noose  forms  a 
slough  which  increases  the  suppurative  action,  both  b}'  undergoing  a 
process  of  disintegration  and  b}^  acting  as  a  foreign  body  in  the  wound. 
Complete  healing  of  a  wound  to  which  a  ligature  has  been  applied  can¬ 
not,  therefore,  possibl}^  take  place  until  after  the  separation  of  the  liga¬ 
ture  and  the  section  of  the  included  arterial  tube. 

These  evils  are  entirely  obviated,  and  union  b}’  the  first  intention  is 
secured,  1,  by  the  use  of  metallic  compressors,  the  needle  and  wire  being 
tolerated  by  the  tissues  amongst  wdiich  the}'  lie,  and  not  acting  as  setons 
in  the  way  that  hempen  or  silken  ligatures  do ;  and  2,  by  the  early  with¬ 
drawal  of  these  compressing  agents,  the  vitality  of  the  artery  not  being 
endangered,  and  no  terminal  slough  resulting. 

That  these  arguments  are  sound  it  is  impossible  to  den}'.  The  prin¬ 
ciple  on  which  acupressure  is  founded  is  in  accordance  with  the  funda¬ 
mental  doctrines  of  sui’gical  pathology,  and  must  commend  itself  to 
every  practical  Surgeon  who  dispassionately  considers  this  important 
question. 

But,  whilst  I  admit  to  the  fullest  the  truth  and  pathological  sound¬ 
ness  of  the  principle  on  which  acupressure  is  founded,  and  whilst  I  can¬ 
not  but  regard  any  method  of  treatment  which  facilitates  the  early 
healing  of  operation-wounds,  without  suppurative  action,  as  a  great 
step  in  advance  of  surgical  practice,  I  cannot  but  think  that,  in  esti¬ 
mating  the  comparative  value  of  the  Ligature  and  of  Acupressure  in 
the  arrest  of  surgical  hemorrhage,  too  much  evil  has  been  laid  to  the 
charge  of  the  thread,  and  too  much  advantage  has  been  claimed  for 
the  needle. 

If  the  ligature  were  the  sole  or  indeed  the  great  cause  of  suppura¬ 
tion  in  wounds,  and  of  the  failure  of  union  by  the  first  intention,  it 
should  undoubtedly  be  discarded  in  favor  of  any  safe  method  that 
would  obviate  these  evils.  But  is  the  ligature  in  reality  so  injurious  ? 
Are  there  not  many  cases  of  want  of  union  by  the  first  intention  which 
are  entirely  independent  of  the  method  adopted  for  occluding  the  arteries? 
The  constitutional  condition  of  the  patient,  irrespective  of  anything  in 


COLLATERAL  CIRCULATION. 


259 


the  local  management  of  the  wound  (p.  1 8),  as  well  as  the  want  of  homo¬ 
geneity  of  tissue  (p.  153),  and  the  very  nature  of  the  wound  itself,  have 
a  most  decided  influence.  In  many  wounds — as  in  operations  for  re¬ 
moval  of  dead  bone,  the  excision  of  bones  and  joints,  the  ablation  of 
many  tumors,  etc., — no  attempt  at  union  by  the  first  intention  is  made  ; 
the  wound  is  stuffed  perhaps  with  lint,  or  the  tissues  are  in  such  a  con¬ 
dition  that  suppuration  is  a  necessity  for  healing. 

So,  again,  in  amputations  (p.  49),  there  are  many  circumstances  that 
militate,  and  always  must  do  so,  against  complete  primary  union. 
Amongst  these  maj^  be  mentioned  the  impossibility  of  close  approxima¬ 
tion  of  the  flaps  owing  to  the  intravention  of  the  bone;  or,  in  some 
amputations,  as  the  partial  ones  of  the  foot,  the  very  shape  of  the  flap, 
and  the  irregularity  of  the  osseous  surfaces;  the  inabilit}^  of  cohesion 
between  alien  tissues,  as  bone  or  synovial  membrane  and  muscle,  etc. 
In  some  cases,  undoubtedly,  where  many  or  deep  ligatures  have  to  be 
applied,  the  threads  add  to  the  difficulty  in  effecting  direct  union.  But 
in  many  amputations  it  must  be  remembered  that  the  chief  and  perhaps 
the  only  ligatures  are  applied  to  vessels  that,  being  cut  long,  are  on  a 
level  with  the  edge  of  the  flap.  This  is  the  case  in  amputation  of  the 
forearm,  and  at  the  shoulder,  hip,  and  knee-joints,  in  amputations  of  the 
leg  low  down,  and  in  all  amputations  done  by  the  long  flap.  In  such 
cases,  acupressure  w’ould  do  little  to  aid  in  accomplishing  direct  union. 

Although,  therefore,  I  do  not  consider  that  the  ligature  is  in  practice 
open  to  the  objection  which  has  been  laid  to  its  charge,  that  it  is  the 
chief  obstacle  to  the  union  of  w^ounds  by  the  first  intention,  yet  nn- 
doubedly  it  is  in  man}^  instances  a  hindrance  to  this  desirable  result; 
and,  when  so,  it  certainly  appears  desirable  that  acupressure  should  be 
substituted  for  it.  In  many  instances  also,  and  in  some  even  where 
union  by  the  first  intention  is  not  possible,  acupressure  is  a  most  con¬ 
venient  and  safe  method  of  arresting  bleeding  from  vessels  which  it  may 
be  very  difficult  to  expose  and  tie.  Thus,  in  lacerated  or  incised  wounds 
of  the  scalp,  in  injuries  of  the  hand  or  fobt,  the  bleeding  may  often  be 
at  once  controlled  bj’^  the  pressure  of  the  needle  and  wire. 

Indeed,  it  appears  to  me,  that  sound  as  maj^  be  the  principle  on  which 
acupressure  is  based,  in  practice  it  cannot  and  need  not  be  substituted 
for  the  ligature,  but  that  it  ma}^  be  employed  advantageously  in  conjunc¬ 
tion  with  it,  each  method  being  applied  to  those  vessels  or  in  those  cases 
to  which  and  in  which  it  seems  most  useful;  and  that  the  Surgeon  will 
act  more  wisel}"  in  being  eclectic  rather  than  dogmatic  in  the  employ¬ 
ment  of  his  means  for  arresting  arterial  hemorrhage,  in  some  cases 
using  styptics,  in  others  compression  or  torsion  or  the  cautery,  acupres¬ 
sure  or  the  ligature,  as  the  particular  case  seems  to  need  it.  Because 
one  method  is  good,  the  others  are  not  necessarily  bad;  because  one  is 
peculiarly  applicable  in  one  case,  it  does  not  follow  that  it  is  equally  so 
in  all. 

Collateral  Circulation. — When  the  main  artery  of  a  limb  has  been 
ligatured,  or  in  any  other  way  occluded,  it  is  only  the  direct  flow  of 
blood  that  is  interrupted ;  the  indirect  supply  which  is  conveyed  into 
the  limb  or  part,  by  the  free  inosculations  between  the  anastomosing 
vessels  of  the  different  portions  of  the  arterial  system,  being  sufficient 
to  preserve  its  vitality,  and  to  prevent  the  occurrence  of  gangrene.  So 
free  and  ready  are  the  communications  kept  up  between  different  por¬ 
tions  of  the  arterial  system,  that,  after  the  largest  arteries  in  the  body, 
such  as  the  subclavian,  iliac,  and  aorta,  have  been  ligatured,  sufficient 
blood  to  support  life  is  at  once  conveyed  into  the  parts  supplied  by 


260 


AKREST  OF  ARTERIAL  HEMORRHAGE. 


them.  This  collateral  circulation  is  most  active  and  most  readil}^  main¬ 
tained  in  early  life,  when  the  vessels  are  pliant  and  elastic,  readily  ac¬ 
commodating  themselves  to  the  increased  quantity  of  blood  that  they 
are  required  to  convey.  As  age  advances,  the  vascular  system  becomes 
less  elastic,  and  there  is  a  greater  difficulty  in  the  establishment  and 
maintenance  of  the  collateral  circulation.  The  anastomosing  vessels 
which  serve  this  purpose  are  invariably  furnished  by  arteries  contiguous 
to  that  which  is  ligatured,  and  come  off  from  the  same  side  of  the  body. 
Thus,  for  instance,  after  the  ligature  of  the  superficial  femoral,  it  is  by 
the  profunda  artery  that  the  supply  of  blood  is  carried  to  the  lower 
extremit3^  Thus  also,  when  the  common  carotid  is  ligatured,  the  circu¬ 
lation  to  the  parts  it  supplies  is  not  maintained  through  the  medium  of 
the  opposite  carotid,  although  the  inosculations  between  the  ultimate 
branches  of  the  two  vessels  are  so  free  upon  the  throat,  upon  the  face, 
and  within  the  cranium ;  but  it  is  b}'  means  of  the  inferior  th^u’oid  and 
vertebral  arteries  (branches  of  the  subclavian  on  the  same  side),  which 
become  greatl}'  enlarged,  that  the  suppl^^  of  blood  is  kept  up  to  the  parts 
on  the  outside,  as  well  as  in  the  inside  of  the  cranium. 

The  suppl}'  of  blood  that  is  sent  to  a  limb,  after  the  deligation  of  the 
main  trunk,  is  at  first  but  small  in  quantity;  being  merely  sufficient  for 
the  maintenance  of  its  vitality,  but  not  enough  for  the  continuance  of 
the  usual  actions  of  the  part.  Hence,  although  the  life  of  a  limb  may 
be  preserved  after  the  ligature  of  its  artery,  it  becomes  cold,  and  the 
patient  is  unable  to  move  it  for  some  time,  the  muscles  appearing  to  be 
completely"  paraly^zed ;  gradualH,  however,  the  supply  of  blood  increases, 
until,  when  it  has  reached  its  usual  standard,  the  normal  vigor  of  the 
part  returns. 

By  what  mechanism  is  this  re-establishment  of  the  blood-supply  ac¬ 
complished?  It  is  due  to  three  series  of  changes  taking  place:  1,  in  the 
Capillaries;  2,  in  the  Anastomosing  Branches  ;  and  3,  in  the  Trunk  itself. 

The  Capillaries  are  the  first  to  enlarge ;  and  this  they  appear  to  do 
by’  a  vital  process,  and  not  in  consequence  of  the  mere  increased  i)res- 
sure  of  the  blood ;  the  temperature  of  the  limb  often  rising,  in  the 
■course  of  a  day  or  two,  to  its  normal  standard,  and  sometimes  to  two 
or  three  degrees  bey^ond  it,  whilst  a  great  sensation  of  heat  is  expe¬ 
rienced  in  it  by  the  patient.  This  period  extends  over  several  weeks; 
and,  if  opportunity  be  afforded  of  examining  the  limb  during  its  con¬ 
tinuance,  the  tissues  generally  will  be  found  to  be  preternaturally  vascu¬ 
lar,  admitting  injection  freely. 

Coincidently  with  this  increase  of  activity  in  the  capillary  system,  the 
Anastomosing  Arteries  of  the  part  enlarge,  becoming  serpentine,  tortu¬ 
ous,  and  w’aved,  forming  circles  or  an  interlaced  net-work.  During  this 
enlargement,  much  pain  is  often  experienced,  owing  to  the  pressure  of 
the  enlarged  vessels  upon  neighboring  nerves.  This  form  of  collateral 
circulation  commences  by  a  general  enlargement  of  all  those  muscular 
and  subcutaneous  secondary^  vessels  of  the  limb,  which  can  normally" 
be  readily  distinguished  by  the  naked  eye.  After  this  general  enlarge¬ 
ment  has  continued  for  some  weeks,  it  tends  to  localize  itself  in  a  few 
of  the  principle  anatomical  inosculations,  until  at  last  it  is  through  their 
medium  that  the  circulation  is  chiefly  maintained.  Thus  for  instance, 
after  the  ligature  of  the  common  carotid,  the  supply  of  blood  is  ulti¬ 
mately"  conveyed  by  the  inosculations  between  the  superior  and  inferior 
thyroid  arteries,  and  by  the  vertebral  and  basilar.  When  the  subclavian 
is  tied,  the  circulation  of  the  upper  extremity  is  carried  on  by  the  anas¬ 
tomoses  between  the  posterior  scapular  and  suprascapular,  and  the 


COLLATERAL  CIRCULATION. 


261 


branches  of  the  axillary  artery  distributed  to  the  vicinity  of  the  shoulder, 
and  between  the  intercostals  and  the  long  and  superior  thoracic;  and 
when  the  external  iliac  is  tied,  the  blood  is  conveyed  to  the  lower  limb 
by  the  inosculations  between  the  mammary  and  lumbar  arteries  and  the 
epigastric  and  circumflex  ilii,  and  by  those  between  the  obturator, 
gluteal,  and  sciatic  arteries  and  the  circumflex  branches  of  the  profunda 
femoris. 

Jones  pointed  out  the  curious  circumstance  that,  when  two  anasto¬ 
mosing  branches  approach  one  another,  they  split,  before  inosculating, 
into  two  or  three  ramusculi,  which  by  uniting  form  a  circle  of  anasto¬ 
moses.  Besides  this  kind  of  collateral  circulation,  Maunoir,  Porta,  and 
Stilling  have  noticed  vessels  running  directly  between  the  extremities  of 
the  obliterated  trunk,  forming  species  of  arterial  shoots,  springing  from 
the  stump  of  the  vessel  (Fig.  110). 


Fig.  109. 


Anastomosing  Circulation  in  Sar- 
torius  and  Pectinens  of  Dog,  three 
months  after  Ligature  of  Femoral. 
(After  Porta.) 


Fig.  110. 


Direct  Anastomosing  Vessels 
of  Right  Carotid  of  Goat,  five 
months  after  Ligature.  (After 
Porta.) 


Fig.  111. 


Change  in  the  trunk  after 
Ligature,  with  Anastomos¬ 
ing  Vessel. 


The  change  that  takes  place  in  the  Trunk  consists  in  its  conversion 
into  a  fibro-cellular  cord,  from  the  point  to  which  the  ligature  has  been 
applied  to  the  first  large  collateral  branch  below  it  (Figs.  109  and  111)  ; 
here  it  becomes  pervious  again,  and,  receiving  the  blood  poured  into  it 
through  the  different  anastomosing  channels,  becomes  again  subservient 
to  the  purposes  of  circulation.  Porta  and  Stilling  have  shown  that,  after 
a  time,  down  the  centre  of  this  fibro-cellular  cord  a  small  tortuous  central 
canal  becomes  developed,  uniting  the  two  distant  ends  of  the  divided 
artery.  This  is  probably  the  last  change  that  takes  place  in  the  estab¬ 
lishment  of  the  collateral  circulation. 

The  collateral  circulation  is  occasionally  not  sufficiently  free  to  pre¬ 
serve  the  integrity  or  vitality  of  the  parts  supplied  by  it.  As  a  conse¬ 
quence  of  this,  gangrene  not  uncommonly  results,  or  the  limb  may  be¬ 
come  paral^^zed  or  atrophied.  This  condition  is  frequently  met  with  in 
old  people,  from  ossification  and  rigidity  of  the  arterial  system  ;  or  it 


262 


AKEEST  OF  ARTERIAL  HEMORRHAGE. 


happen  as  the  result  of  copious  hemorrhage,  or  of  an  extensive 
transverse  wound  of  the  limb  dividing  many  of  the  anastomosing  vessels. 
It  more  rarely  happens  that  we  find  too  great  freedom  of  the  anasto¬ 
moses,  so  as  to  lead  to  a  failure  of  the  purposes  for  which  the  ligature 
has  been  applied,  by  the  rapid  admission  of  blood  into  the  distal  side  of 
the  vessel,  thus  perhaps  occasioning  secondary  hemorrhage. 

ACCIDENTS  AFTER  ARTERIAL  OCCLUSION  BY  SURGICAL  MEANS. 

The  accidents  tliat  may  follow  the  application  of  the  ligature,  the  use 
of  acupressure,  or  of  compression  in  any  way  exercised  upon  'wounded 
arteries,  are  Secondary  Hemorrhage  and  Gangrene  of  the  Limb. 

Secondary  or  Recurrent  Hemorrhage. — By  this  is  meant, 
bleeding  from  any  cause  after  the  emplo3^ment  of  the  means  above  men¬ 
tioned.  This  accident  ma}^  arise  from  a  variety  of  circumstances,  which 
may  be  divided  into  two  great  classes  :  1.  Local  Causes^  dependent  on 

the  Vessel  or  Ligature  ;  and  2.  Constitntional  Causes^  connected  with 
some  Morbid  Condition  of  the  Constitution  or  Blood,  in  consequence  of 
which  those  changes  which  are  necessary  for  occlusion  of  the  artery  do 
not  take  place. 

Local  Causes. — Among  this  class  of  causes  may  be  mentioned  any 
imperfection  in  the  application  of  the  ligature.,  needle.,  or  compress ;  as,  for 
instance,  the  ligature  being  tied  too  loosely,  or  with  the  inclusion  of  a 
portion  of  nerve,  vein,  or  muscle  ;  so  also  the  accidental  puncture  of  the 
artery  above  the  point  to  which  the  ligature  is  applied. 

The  rush  of  blood  through  a  neighboring  trunk  or  collaieral  branch 
immediatelv  above  the  ligature  has  been  considered  as  likely  to  inter¬ 
fere  with  the  formation  of  the  internal  plug;  but  too  much  importance 
should  not  be  attached  to  this,  for  Porter  has  tied  the  carotid  success¬ 
fully^  within  one-eighth  of  an  inch  of  the  brachio-cephalic  artery  ;  Bell¬ 
ingham  has  ligatured  the  external  iliac  close  to  its  origin ;  and  Key’^,  the 
subclavian  in  the  vicinity^  of  a  large  branch,  without  secondary  hemor¬ 
rhage  ensuing.  But  although  the  ligature  may  be  safely  applied  near  a 
branch  on  its  proximal  side,  I  think  that  the  presence  of  a  collateral 
branch  in  close  proximity  to  the  distal  side  of  the  ligature — more  espe¬ 
cially  if  it  be  one  that  serves  to  carry  on  the  anastomosing  circulation — 
will  be  found  to  have  a  decided  tendency^’  to  prevent  the  occlusion  of  the 
distal  end  of  the  artery,  and  thus  to  favor  the  occurrence  of  secondary 
hemorrhage. 

The  ivound  of  a  collateral  branch  immediately  above  the  ligature, 
though  it  do  not  give  rise  to  troublesome  hemorrhage  at  the  time,  will,  as 
I  have  seen,  cause  furious  bleeding  as  the  collateral  circulation  becomes 
established. 

A  diseased  state  of  the  coats  of  the  artery  at  the  point  deligated  or 
compressed  will  occasion  rapid  sloughing  and  unhealthy  ulceration  of 
the  vessel ;  those  plastic  changes  which  are  necessary  for  its  occlusion 
not  going  on  within  it.  It  has  happened  that  fatal  secondary^  hemorrhage 
has  occurred  from  a  large  arteiy,  such  as  the  femoral,  in  consequence 
of  a  small  atheromatous  or  calcareous  patch  having  given  way  imme¬ 
diately  above  the  ligature,  a  day  or  two  after  its  application. 

Constitutional  Causes. — These  act  by  preventing  the  formation  of  a 
clot  within,  and  the  deposit  of  plastic  matter  without,  the  artery;  or  by 
causing  their  absorption  in  a  few  days,  if  they  have  been  formed.  (Figs. 
102  and  103.)  Amongst  the  most  common  of  these  causes  are  those 
unhealthy’’  states  of  the  sy^stem  in  which  diffused  erysipelatous  inflam- 


SECONDARY  HEMORRHAGE. 


263 


mation  sets  ’in,  which  is  incompatible  with  plastic  effusion.  In  these 
cases  either  no  internal  coagulum  at  all  is  formed,  or  it  is  weak,  imper¬ 
fect,  and  unable  to  resist  the  impulse  of  the  blood  ;  speedily  becoming 
absorbed  or  disintegrated,  and  being  washed  away.  There  are  also  cer¬ 
tain  states  of  the  blood  in  which  from  disease,  as  albuminuria,  it  has  lost 
its  plasticity,  and  cannot  yield  the  products  of  adhesive  inflammation. 
Secondary  hemorrhage  is  specially  apt  to  occur  in  cases  of  pyaemia^  pro¬ 
vided  that  disease  assume  a  somewhat  chronic  character.  The  condition 
of  the  blood  in  pyaemia  being  incompatible  with  the  formation  of  a  firm 
and  plastic  coagulum  within  the  arteiy,  the  vessel  continues  or  becomes 
open,  and  secondary  hemorrhage  will  certainly  occur. 

In  some  cases  the  secondary  hemorrhage  appears  to  be  due  to  an 
excited  state  of  the  circulation.  The  patient  is  restless,  and  has  a  quick, 
irritable,  and  jerking  pulse.  In  such  circumstances,  bleeding  is  very  apt 
to  occur,  and,  if  not  too  abundant,  appears  to  give  relief  to  the  system. 

The  occurrence  of  erysipelas^  phlebitis.,  or  sloughing  of  the  stump  or 
wound.,  will  prevent  or  arrest  the  necessary  adhesive  inflammation.  The 
sloughing  action  set  up  in  a  wound  may  extend  to  the  larger  arteries, 
and  by  destroying  their  coats  occasion  secondary  hemorrhage.  But  it 
must  be  borne  in  mind  that  the  arterial  tissues  are  usually  the  last  of  the 
soft  tissues  to  slough.  An  artery  will  continue  to  pulsate  in  a  wound, 
preserving  its  integrity  when  all  around  it  is  slough  and  disorganization. 

Phenomena. — The  occurrence  of  secondary  hemorrhage  is  usually 
somewhat  gradual,  and  not  without  warning.  The  blood  does  not  burst 
forth  in  a  gush  at  once,  but  appears  at  first  in  a  small  quantity,  oozing 
out  of  the  wound  and  staining  the  dressings;  it  may  then  cease  to  flow 
for  a  time,  but  breaks  out  again  in  the  course  of  a  few  hours,  welling  up 
freely  in  the  wound,  and  either  draining  the  patient  by  repeated  losses, 
attended  by  the  phenomena  that  characterize  hemorrhagic  fever,  or  else 
exhausting  him  so  that  he  falls  a  victim  to  some  asthenic  disease,  such 
as  pneumonia,  erysipelas,  or  phlebitis.  In  other  cases  again,  after  a  few 
w'arnings,  it  may  burst  out  in  a  gushing  stream  that  at  once  destroys 
life. 

The  opportunities  which  I  have  had  of  examining  the  state  of  the 
vessels  in  several  cases  of  fatal  secondary  hemorrhage,  lead  me  fully  to 
concur  with  Guthrie  and  Porter,  that  the  blood  in  the  great  majority  of 
instances  comes  from  the  distal  and  not  from  the  proximal  side  of  the 
wound!  The  greater  tendency  in  the  distal  end  of  the  vessel  to  bleed, 
appears  to  arise  partly  from  the  less  perfect  occlusion  of  this  portion  of 
the  artery,  and  partly  from  its  greater  liability  to  slough,  in  consequence 
of  the  ligature  interrupting  its  supply  of  blood  through  the  vasa  vasorum. 
It  is  no  objection  to  this  opinion  that  the  fatal  hemorrhage  is  often 
arterial;  for,  though  it  is  true  that  the  blood  which  is  carried  to  the  distal 
end  is,  for  the  first  few  days  after  the  application  of  a  ligature,  of  a 
venous  hue,  yet,  after  the  collateral  circulation  is  once  established,  it 
gradually  assumes  a  more  scarlet  tint,  and  at  last  becomes  completely 
arterialized. 

Periods  at  which  it  occurs. — Secondar}’’  hemorrhage  may  come  on  at 
any  time  between  the  application  of  the  ligature  and  the  closure  of  the 
wound.  There  are,  however,  three  periods  at  which  it  is  particularly  apt 
to  occur:  1,  a  few  hours  after  the  ligature  has  been  applied;  2,  about 
the  period  of  the  separation  of  the  ligature ;  and,  3,  at  an  indefinite  time 
after  its  separation. 

1.  The  hemorrhage  which  occurs  a  few  hours  after  the  application  of 
the  ligature.,  commonly  called  reactionary  or  intermediate.,  comes  on  as 


264 


AEKEST  OF  AKTEKIAL  HEMOKRHAGE. 


the  patient  recovers  from  the  depressing  influence  of  the  chloroform  or 
from  the  shock  of  the  operation,  and  arises  from  some  imperfection  in 
the  t3dng  of  the  ligature.  That  which  occurs  some  days  afterwards 
arises  from  disease  in  the  arterial  coats,  causing  them  to  give  way  ;  from 
slouo:hino::  or  from  want  of  adhesive  inflammation  on  the  face  of  a 
stump.  When  it  arises  from  the  latter  cause,  there  is  a  general  oozing 
or  dribbling  of  blood  from  many  points  of  the  surface,  rather  than  a 
gush  from  one  orifice.  In  those  cases  in  which  the  artery  has  been  tied 
above  the  wound  onl}",  hemorrhage  is  very  apt  to  occur  at  this  time. 

2.  When  hemorrhage  occurs  about  the  time  of  the  separation  of  the 
ligature^  it  may  arise  from  any  of  the  causes  alread^^  specified  that  in¬ 
terfere  with  the  due  formation  of  an  internal  coagulum,  or  that  occasion 
ulceration  and  sloughing  of  the  coats  of  the  vessel.  The  occurrence  of 
hemorrhage  at  this  time  is  often  connected  with,  or  dependent  upon, 
that  peculiar  irritability  of  the  heart  and  arteries  which  has  already  been 
mentioned  as  a  frequent  cause  of  bleeding. 

3.  Lastly,  in  some  cases  in  which  the  ligature  has  separated  hut  the 
wound  has  remained  open^  the  hemorrhage  may  take  place  either  from 
the  cicatrix  in  the  arteiy  being  too  weak  to  support  the  impulse  of  the 
blood ;  or  from  the  coagulum  being  absorbed  in  the  way  already  men¬ 
tioned.  The  continuance  of  the  open  state  of  the  wound  after  the  sepa¬ 
ration  of  the  ligature,  is,  I  think,  not  improbably  dependent  upon  a 
morbid  condition  of  the  coats  of  the  vessel  which  eventually’  leads  to 
hemorrhage.  The  length  of  time  that  will  sometimes  elapse  between 
the  separation  of  the  ligature  and  the  occurrence  of  hemorrhage  is  very 
remarkable;  thus  there  is  in  St.  Thomas’s  Hospital  a  preparation  of  a 
carotid  artery,  from  which  secondary  hemorrhage  took  place  in  the  tenth 
week  after  ligature;  and  South  mentions  a  case  of  ligature  of  the  sub¬ 
clavian  in  which  the  thread  separated  on  the  twenty-seventh  day,  the 
fatal  hemorrhage  occurring  in  the  thirteenth  week. 

o  o 

The  Treatment  of  Secondary  Hemorrhage  must  be  considered,  as  the 
bleeding  takes  place,  1,  from  a  Stump  ;  and,  2,  from  an  Arteiy  tied  in  its 
Continuity’. 

In  all  cases  of  ligature  of  arteries,  care  should  of  course  be  taken  to 
prevent,  if  possible,  this  accident,  by^  keeping  the  patient  perfectly  quiet, 
giving  no  stimulants,  having  the  bowels  kept  open  and  the  secretions 
free,  and  avoiding  any  undue  traction  on  the  ligature  itself 

In  primary  hemorrhage  the  rule  of  practice  is,  not  to  interfere  by’’ 
operation  if  once  the  bleeding  have  been  arrested  by  other  means.  In 
secondary  hemorrhage  this  rule  of  practice  does  not  apply;  but  the 
Surgeon  may  proceed  to  adopt  efiectual  means  for  the  prevention  of  the 
recurrence  of  the  bleeding  after  the  first  outbreak,  even  though  all  flow 
of  blood  have  ceased  when  he  sees  the  patient ;  and  he  must  do  so,  and 
that  without  delay,  if  the  hemorrhage  have  recurred  more  than  once. 
When  once  a  repetition  of  secondary  hemorrhage  has  taken  place,  the 
patient’s  condition  becomes  most  critical;  the  efforts  of  nature  can  no 
longer  be  trusted  to  for  the  arrest  of  the  bleeding,  and  the  last  and  fatal 
gush  may  at  any^  moment  occur.  Hence  the  Surgeon  must  in  such 
circumstances  lose  no  time;  there  must  be  no  dallying,  no  hoping  that 
the  bleeding  will  not  recur,  no  trusting  to  temporary  and  inefficient 
expedients,  but  the  case  must  be  at  once  and  decisively  taken  in  hand. 
In  no  circumstances  are  more  coolness  and  more  surgical  knowledge 
required,  than  in  adopting  a  decisive  and  immediate  line  of  action  in  a 
case  of  secondary  hemorrhage.  There  is  no  time  for  delay,  no  time  for 


TEEATMENT  OF  SECONDARY  HEMORRHAGE. 


285 


consultation,  none  for  reference  to  books;  but  the  Surgeon  must  act  at 
once  on  his  own  responsibility. 

1.  The  treatment  of  secondary  hemorrhage  from  a  Stump  will  depend 
in  a  great  measure  on  the  degree  of  union  that  has  taken  place  between 
the  flaps,  and  on  the  situation  of  the  stump. 

When  the  hemorrhage  occurs  a  few  days  after  amputation,  if  there  be 
but  slight  oozing,  elevating  the  part,  applying  cold,  and  bandaging  it 
tightly  with  a  roller,  so  as  to  compress  the  flaps,  will  sometimes  arrest 
the  bleeding.  If  it  continue,  however,  or  become  more  scA^ere,  the  flaps, 
Avhich  will  have  been  disunited  by  the  effusion  of  blood,  must  be  separated, 
and  the  bleeding  vessels  sought  for  and  tied.  When  the  stump  is  sloughy, 
and  the  tissues  softened,  the  ligatures  will  not  hold ;  in  these  circum¬ 
stances  the  application  of  the  actual  cautery  to  the  bleeding  points  will 
arrest  the  flow  of  blood.  If  the  oozing  appear  to  be  nearly  general  from 
the  number  of  points,  the  flaps  being  somewhat  spongy,  I  have  succeeded 
in  arresting  the  hemorrhage  by  clearing  their  surfaces  thoroughly  of  all 
coagula,  and  then  bringing  them  tightly  together  b}"  means  of  a  roller. 

If  the  hemorrhage  occur  at  a  later  period,  after  the  tenth  day,  when 
tolerable  union  has  taken  place,  and  if  it  appear  to  proceed  from  the 
principal  artery  of  the  part,  an  effort  may  be  made  to  arrest  it  by  the 
application  of  the  horse-shoe  tourniquet,  which  occasionally  will  stop  all 
further  loss  of  blood ;  or,  if  the  union  that  had  taken  place  between  the 
flaps  have  been  broken  through,  the  stump  ma}^  be  fairlj’’  opened  up,  the 
coagula  turned  out,  and  the  bleeding  vessel  sought  for  and  tied.  If,  how¬ 
ever,  notwithstanding  the  hemorrhage,  the  union  between  the  flaps  con¬ 
tinue  sound  and  firm,  then  the  choice  lies  between  three  alternatives ;  I, 
opening  up  the  stump,  clearing  awa}'  coagula,  and  t3dng  the  bleeding 
vessels  at  their  open  mouths;  2,  ligaturing  the  main  arteiy  just  above 
the  stump ;  3,  performing  the  Hunterian  operation,  and  tjdng  the  vessel 
high  up  in  the  limb  at  a  distance  from  the  stump.  The  course  to  be 
adopted  will,  I  think,  in  a  great  measure  depend  upon  the  stump  with 
which  Ave  haA’e  to  do;  but  as  a  general  rule  I  prefer  in  these  cases 
adopting  the  first  alternatiA^e,  placing  a  tourniquet  on  the  limb,  passing 
the  finger  into  the  stump,  and  breaking  up  all  adhesions,  which  are  often 
A’eiy  firm  ;  then  turning  out  the  mass  of  coagula,  which  will  usuall}^  be 
found  distending  the  flaps,  clearing  these  thoroughl}"  with  a  sponge,  and 
then  t3dng  the  bleeding  arteiy.  Besides  the  main  arteiy  that  bleeds — 
one  of  the  tibials,  for  instance,  if  it  be  a  leg-amputation — there  will 
generally  be  Amiy  free  oozing  from  man3’  points.  The  more  abundant 
of  this  ma3"  be  stopped  ly  the  ligature  passed,  if  the  tissues  be  friable, 
b3"  means  of  a  meAuis-needle  under  the  A’essels.  The  rest  will  cease  on 
the  application  of  cold  water  and  on  raising  the  stump.  The  flaps  ma3’’ 
then  be  brought  together  b3'’  strips  of  plaster  and  a  bandage,  and  will 
usuall3'  veiy  readil3"  unite. 

Should,  howeA'er,  the  stump  be  inflamed,  slougly,  and  oedematous,  and 
more  particularl3"  if  it  be  merel3^  the  foot  or  hand  that  has  been  remoAmd, 
then,  instead  of  opening  it  up,  and  seeking  for  the  bleeding  vessel, 
deepl3’'  hidden  in  infiltrated  tissues,  it  will  be  better  to  tie  the  main 
arteiy  of  the  limb  just  above  the  flaps,  or  AvhereA'er  it  ean  be  most 
readily  reached.  In  such  cases,  after  amputation  of  the  foot,  I  haA^e  suc- 
cessfull3^  tied  the  posterior  tibial  Ioav  down,  just  above  the  malleolus. 

The  third  alternative,  that  of  ligaturing  the  artery  high  above  the 
stump,  should,  I  think,  in  the  first  instance,  be  undertaken  in  those  cases 
onl3’  where  the  amputation  has  been  done  close  to  the  trunk,  as  at  the 
shoulder-joint,  or  the  middle  or  upper  part  of  the  thigh,  and  where  con- 


266 


ARKEST  OF  ARTERIAL  HEMORRHAGE. 


sequentl}’’  there  is  no  length  of  limb  to  be  nourished  by  the  artery  that 
is  ligatured,  and  w’here  opening  up  an  almost  cicatrized  stump  of  veiy 
large  size  would  inflict  a  greater  shock  upon  the  S3"stem,  and  more  con¬ 
secutive  danger,  than  the  deligation  of  an  arteiy  by  an  independent 
operation.  Hence,  although  in  no  case  of  secondaiy  hemorrhage  from 
a  leg-stump  below  the  knee  would  I  ligature  the  femoral  in  preference 
to  opening  up  the  flaps  and  securing  the  vessels  in  them,  if  this  were 
practicable,  j^et  in  secondary  hemorrhage  after  the  amputation  of  the 
thigh,  the  case  might  be  different;  and  here,  if  good  union  had  already’’ 
taken  place,  and  the  stump  were  not  distended  by  coagula,  the  main 
artery  might  be  tied.  In  such  cases  it  is  clearly  useless  to  ligature  the 
superficial  femoral,  as  the  hemorrhage  mav",  and  most  probably  does, 
proceed  from  some  of  the  branches  of  the  profunda.  Ligature  of  the 
common  femoral  is  not  very  successful ;  and  upon  the  whole  it  would,  I 
think,  be  safer,  if  all  other  means  have  been  tried  and  have  failed,  to 
deligate  the  external  iliac  just  above  Poupart’s  ligament.  In  disarticu¬ 
lation  of  the  arm  at  the  shoulder-joint,  the  subclavian  arteiy  must  be 
tied,  either  above  or  just  below  the  clavicle. 

In  any  case,  the  ligature  of  the  main  artery  of  the  limb  becomes  the 
only  and  the  last  resource,  where,  in  consequence  of  the  softened,  in¬ 
flamed,  infiltrated  or  sloughj"  state  of  the  tissues,  the  Surgeon  is  unable 
to  secure  the  bleeding  vessels  in  the  stump  itself,  the  ligatures  cutting 
throimh  the  disorganized  coats  of  the  vessels. 

2.  When  the  hemorrhage  occurs  after  a  ligature  has  been  applied  to 
the  Continuity  of  the  Vessel^  whether  for  injury  or  disease,  pressure 
must  first  be  tried.  With  this  view  the  wound  should  be  plugged,  and 
a  graduated  compress  should  be  very  firmly  and  carefullj'  applied  by 
means  of  a  ring-tourniquet  over  the  point  from  which  the  blood  pro¬ 
ceeds  ;  in  this  wa}^  the  bleeding  maj^  occasional!}'-  be  stopped.  Xot 
unfrequentl}^,  however,  this  will  prove  ineffectual,  the  bleeding  recurring 
from  underneath.  When  this  is  the  case,  what  should  the  Surgeon  do? 
He  ma}'^  reapply  the  compress  once  more  with  great  care,  after  clearing 
awa}"  coagula,  and  drying  the  parts  thoroiighl}’ ;  but  should  it  again  fail 
in  arresting  the  bleeding,  it  is  useless  to  trust  to  it  again,  as  the  hemor¬ 
rhage  will  certainly  recur,  and  valuable  time  and  much  blood  will  be 
lost  in  these  fruitless  attempts  at  checking  it.  In  such  a  case  as  this, 
the  Surgeon  must  clearl}^  and  decidedl}^  determine  on  the  course  to  be 
pursued,  as  there  is  but  little  time  for  reflection  or  consultation,  and 
none  for  referring  to  authorities. 

If  the  arteiy  be  situated  on  the  trunk,  as  the  subclavian,  carotid,  or 
one  of  the  iliacs,  there  is  nothing  to  be  done,  but  to  trust  to  the  plug¬ 
ging  of  the  wound;  and  in  the  great  majority  of  these  cases  the  patient 
will  die  exhausted  by  repeated  hemorrhage. 

When  the  artery  is  situated  in  one  of  the  limbs,  more  efficient  pro¬ 
cedures  ma}"  be  emploj^ed.  If  it  be  one  of  the  arteries  of  the  upper 
extremit}'-,  the  wound  should  be  opened  up,  and  an  attempt  made  to  tie 
both  ends  of  the  vessel  again  in  this;  should  this  fail,  or  not  be  practi¬ 
cable,  the  arteiy  must  be  deligated  at  a  higher  point  than  that  at  which 
it  had  been  previousl}^  tied;  should  the  hemorrhage  continue,  or  be 
re-established,  amputation  is  the  only  resource  left. 

In  the  lower  extremit}",  the  treatment  of  secondaiy  hemorrhage  occur¬ 
ring  after  ligature  is  replete  with  difficult}".  Here  I  believe  it  to  be 
useless  to  tie  the  artery  at  a  higher  point  than  that  to  which  the  ligature 
has  been  already  applied,  as  gangrene  invariably  follows  this  double 
ligature  of  the  arteries  of  the  lower  extremity:  at  least,  in  the  two  or 


GANGRENE  AFTER  LIGATURE. 


267 


three  cases  that  I  have  seen  in  which  recourse  has  been  had  to  this 
practice,  mortification  of  the  limb  has  ensued;  and  in  all  the  reported 
cases  with  which  I  am  acquainted,  a  similar  result  has  occurred.  The 
treatment  should  var}'  according  as  we  have  the  femoral  arteiy  or  one 
of  the  tibials  to  deal  with.  If  the  hemorrhage  proceed  from  the  femoral, 
I  should  be  disposed  to  cut  down  on  the  bleeding  part  of  the  vessel, 
treating  it  as  a  wounded  artery,  and  applying  a  ligature  above  and 
I)elow  the  part  alread}’’  deligated;  this  operation  would,  however,  neces¬ 
sarily  be  fraught  with  difficulty.  Should  this  be  impracticable,  or  not 
succeed  in  checking  the  hemorrhage,  I  think  that  we  should  best  consult 
the  safety  of  the  patient  by  amputating  at  once  on  a  level  with  or  above 
the  ligature.  Although  this  is  an  extreme  measure,  it  is  infinitely’  pre¬ 
ferable  to  allowing  him  to  run  the  risk  of  the  supervention  of  gangrene, 
which  will  require  removal  of  the  limb  under  less  favorable  conditions. 
If  the  secondary’  hemorrhage  proceed  from  one  of  the  tibials,  it  would 
be  useless  to  adopt  either  of  the  preceding  alternatives.  If  we  ligatured 
the  superficial  femoral,  the  bleeding  would  not  be  permanently’  con¬ 
trolled,  or,  if  it  were,  gangrene  of  the  limb  would  in  all  probability  set 
in;  at  least,  I  know  of  no  case  in  which  this  practice  has  been  followed 
without  mortification  occurring.  In  a  few  rare  instances,  however,  the 
ligature  of  the  popliteal  has,  in  such  circumstances,  succeeded:  but  it 
has  also  frequently  failed,  rendering  secondary  amputation  necessary, 
and  its  success  is  a  mere  matter  of  chance.  The  depth  at  which  the  tibials 
are  situated  is  so  great,  that  it  would  be  hopeless  to  search  for  one  of 
these  vessels  and  attempt  its  deligation  at  the  bottom  of  a  deep,  sloughy’, 
infiltrated,  and  inflamed  w’ound.  In  such  circumstances,  therefore,  I 
think  we  should  amputate  the  leg  above  the  seat  of  wound.  This  is 
truly’  a  severe  measure;  but  the  only’  other  alternative  that  has  to  my 
knowledge  ever  succeeded,  is  the  ligature  of  the  popliteal ;  and  as  that, 
as  has  already’  been  stated,  has  frequently’  failed,  I  think  that,  as  a  rule, 
we  should  best  consult  the  safety’  of  the  patient  by  the  removal  of  the 
limb  at  once. 

If  the  hemorrhage  occur  from  a  wounded  arteiy  to  which  ligatures 
have  already  been  applied  above  and  below  the  seat  of  wound,  the 
same  treatment  must  be  adopted  as  in  those  cases  in  which  the  bleeding 
takes  place  from  the  application  of  the  ligature  to  the  continuity’  of  the 
vessel. 

Gangrene  following  Ligature. — After  the  ligature  of  the  main 
artery’-  of  a  limb,  the  collateral  circulation  is,  under  all  ordinary’  circum¬ 
stances,  sufficient  to  maintain  the  vitality  of  the  part  supplied  by  the 
deligated  vessel.  In  some  cases,  however,  it  happens  that  the  condition 
of  the  circulation  in  the  parts  below  the  ligature  is  not  compatible  with 
their  life. 

Causes. — The  causes  influencing  the  occurrence  of  gangrene  in  this 
way  are  the  Age  of  the  Patient,  the  Seat  of  the  Operation,  and  the 
various  Conditions  in  w’hich  the  Limb  may^  afterwards  be  placed. 

The  influence  of  age  is  not,  however,  so  marked  as  might  a  priori  be 
supposed  ;  for,  although  there  can  be  no  doubt  that  there  is  a  less  accom¬ 
modating  power  in  the  arterial  sy’stem  to  vary’ing  quantities  of  blood  at 
an  advanced  period  of  life,  and  that  there  would  be  greater  difficulty’  in 
maintaining  the  vitality^  of  the  limb  after  ligature  of  the  artery’  in  a  man 
of  sixty  than  in  one  of  twenty’-five ;  y’et  I  find  that,  of  thirty’  cases  .in 
w’hicli  gangrene  of  the  lower  extremity’  followed  the  ligature  either  of  the 
external  iliac  or  femoral  arteries,  the  average  age  of  the  patient  was 
thirty’-five  y’ears,  as  nearly’  as  possible  the  mean  age  at  which  these  ope- 


268 


ARREST  OF  ARTERIAL  HEMORRHAGE. 


rations,  according  to  Norris’s  Tables,  are  generally  performed.  Of  these 
cases  of  gangrene  two  occurred  under  twenty  years  of  age,  eleven 
between  twenty  and  thirty,  eight  between  thirty  and  forty,  and  nine 
above  forty. 

The  seat  of  the  operation  influences  greatly  the  liability  to  gangrene, 
which  is  much  more  frequent  after  the  ligature  of  the  arteries  in  the 
lower  than  in  the  upper  extremit3\ 

Besides  these  predisposing  causes,  gangrene  after  ligature  may  be- 
directly  occasioned  by  a  deficient  supply  of  arterial  blood.  In  some 
cases  this  may  arise  from  the  collateral  vessels  being  unable,  in  conse¬ 
quence  of  the  rigidity  of  their  coats,  to  accommodate  themselves  to  the 
increased  quantity  of  blood  which  the}^  are  required  to  transmit ;  or  they 
ina}^  be  compressed  in  such  a  way  by  extravasation  as  to  be  materially 
lessened  in  their  capacity".  In  other  instances  again,  the  existence  of 
cardiac  disease  ma}'-  interfere  with  the  proper  supply  of  blood  to  the  part. 

Great  loss  of  blood.,  either  in  consequence  of  secondary  hemorrhage,  or 
in  an^’-  other  way,  before  or  after  the  application  of  the  ligature,  is  often 
followed  by  gangrene,  and  is  almost  certain  to  be  attended  by  this 
result  if  a  second  ligature  have  been  applied  to  a  higher  point  in  the 
lower  extremity.  That  a  diminution  in  the  quantit}^  of  blood  circulating 
in  the  system  ma^q  under  the  most  favorable  circumstances,  become  a 
cause  of  gangrene  after  the  ligature  of  the  arteiy,  is  illustrated  by  the 
statement  of  Hodgson  that,  soon  after  the  introduction  of  the  Hunterian 
operation  into  Paris,  it  was  the  custom  to  employ  repeated  venesection 
in  the  cases  operated  on  ;  the  consequence  of  which  was,  that  mortifi¬ 
cation  was  of  frequent  occurrence. 

A  more  common  cause  of  gangrene  is  the  difficulty  experienced  by 
the  venous  blood  in  its  return  from  the  limb.  This  difficulty  alwa3^s 
exists  even  when  no  mechanical  obstacle  impedes  the  return,  being  de¬ 
pendent  on  the  want  of  a  proper  vis  a  tergo  to  drive  on  the  blood.  The 
propulsive  power  of  the  heart,  the  main  agent  in  the  venous  circulation, 
is  greatly  diminished  by  being  transmitted  through  the  narrow  and  tor¬ 
tuous  channels  of  the  anastomosing  vessels.  This  difficulty  to  the 
onward  passage  of  the  venous  blood  ma3q  if  there  exist  any  cause  of 
obstruction  in  the  larger  venous  trunks,  be  readily  increased  to  such  an 
extent  as  to  choke  the  collateral  circulation,  and  so  cause  the  limb  to 
mortif3^  The  mechanical  obstacle  may  be  dependent  upon  the  occlusion 
of  the  vein  by  inflammation  excited  within  it  opposite  the  ligature,  by 
its  transfixion  with  the  aneurism-needle,  or  by  its  accidental  wound  with 
the  knife  in  exposing  the  arteiy.  When  such  an  injury,  followed  by  in¬ 
flammation,  is  inflicted  on  a  vein,  which,  like  the  femoral,  returns  the 
great  mass  of  blood  from  a  limb,  gangrene  is  the  inevitable  result. 

The  supervention  of  erysipelas  in  the  limb  after  the  application  of  the 
ligature,  though  fortunately  not  a  very  frequent  occurrence,  is  a  source 
of  considerable  danger,  being  very  apt  to  give  rise  to  gangrene  by  the 
tension  of  the  parts  obstructing  the  amastomosing  circulation.  I  have 
on  two  occasions  seen  gangrene  of  the  fingers,  from  this  cause,  follow 
ligature  of  the  vessels  of  the  forearm. 

The  abstraction  of  heat  from  the  limb,  either  directly  by  the  applica¬ 
tion  of  cold,  or  indirectly  by  the  neglect  of  sufficient  precaution  to  keep 
up  the  temperature  of  the  part,  often  occasions  gangrene  :  thus  Sir  A. 
Cooper  saw  mortification  follow  the  application  of  cold  lead-lotion  to  a 
limb  in  which  the  femoral  artery  had  been  tied  ;  and  Hodgson  witnessed 
the  same  result  when  the  operation  was  performed  at  an  inclement  season 
of  the  3'ear. 


GANGRENE  AFTER  LIGATURE. 


269 


The  incautious  application  of  heat  may,  by  overstimulating  the 
returning  circulation  of  the  limb,  especially  about  that  period  when  the 
rising  temperature  is  an  indication  of  increased  action  in  the  capillary 
vessels,  occasion  mortification.  In  this  way  the  application  of  hot 
bricks  and  bottles  to  the  feet  has  given  rise  to  sloughing ;  and  Liston 
was  compelled  to  amputate  the  thigh  after  ligature  of  the  femoral  arteiy, 
for  gangrene  induced  by  fomenting  the  limb  with  hot  water. 

The  application  of  a  bandage^  even  though  very  cautiousl}^  made,  is 
apt  to  induce  sloughing  and  gangrene.  I  have  seen  this  happen  when  a 
roller  was  applied  to  the  leg  after  ligature  of  the  femoral  artery,  with  a 
view  of  removing  the  oedema. 

The  Period  of  Supervention  of  gangrene  of  the  limb  extends  over  the 
first  three  or  four  weeks  after  the  ligature  of  the  vessel.  It  seldom  sets 
in  before  the  third  day,  but  most  frequently  happens  before  the  tenth. 

Character. — The  gangrene  from  ligature  of  an  artery  is  almost  inva¬ 
riably  of  the  moist  kind,  on  account  of  the  implication  of  the  veins. 
The  limb  first  becomes  oedematous ;  vesications  then  form ;  and  it 
assumes  a  purplish  or  greenish-black  tint,  rapidly  extending  up  to  the 
seat  of  operation.  In  some  cases,  though  they  are  rare,  simple  mummi¬ 
fication  of  the  limb  comes  on;  the  skin  assuming  a  dull  yellowish-white 
hue,  mottled  by  the  streaks  that  correspond  to  the  veins,  and  becoming 
diy,  horny,  and  shrivelled,  about  the  extensor  tendons  of  the  instep. 

Treatment. — Much  may  be  done  with  the  view  of  preventing  gangrene. 
Thus,  the  limb  should  be  elevated,  wrapped  up  loosely  in  flannel  or 
cotton-wadding,  and  laid  on  its  outer  side  after  the  operation.  If  the 
weather  be  cold,  hot-water  bottles  may  be  put  into  the  bed,  but  not  in 
contact  wdth  the  limb.  Should  there  be  an}'  appearance  of  stagnation 
of  venous  blood,  the  plan  recommended  by  Guthrie  of  emplojdng  con¬ 
tinuous  and  methodical  friction  in  a  direction  upwards  for  twenty-four 
hours,  so  as  to  keep  the  superficial  veins  emptied,  may  be  practised. 

When  mortification  has  fairly  set  in,  amputation  of  the  limb  should 
be  performed  at  once  as  the  only  chance  of  saving  life,  in  all  those  cases 
in  which  the  patient’s  constitutional  powers  are  sufficiently  strong  to 
enable  him  to  bear  the  shock  of  the  operation.  The  limb  should  be 
removed  at  the  seat  of  the  original  wound,  or  opposite  the  point  at  which 
the  artery  has  been  tied.  In  those  cases,  however,  in  which  the  gan¬ 
grene  follows  injuiy  of  the  femoral  arteiy  just  below  Poupart’s  ligament, 
Guthrie  advises  the  amputation  to  be  done  below  the  knee,  where  it 
usuall}^  stops  for  a  time.  If  the  gangrene  spread,  with  oedema  or  serous 
infiltration  of  the  limb,  the  amputation  should  be  done  high  up ;  at  the 
shoulder-joint,  or  in  the  upper  third  of  the  thigh.  In  these  cases  a 
large  number  of  vessels  usually  require  ligature,  having  been  enlarged 
by  the  collateral  circulation. 


270 


TRAUMATIC  ANEURISM. 


CHAPTER  XY. 

TRAUMATIC  ANEURISM  AND  ARTERIO-YENOUS  WOUNDS. 

TRAUMATIC  ANEURISM. 

We  have  hitherto  discussed  the  treatment  of  an  injured  artery  having 
an  open  wound  communicating  with  it.  It  often  happens,  however,  that 
the  case  is  not  so  simple  as  has  been  described,  but  that,  in  addition  to 
the  wound  in  the  vessel,  there  is  subcutaneous  extravasation  of  blood, 
with  more  or  less  pulsation,  thrill,  and  bruit,  from  the  projection  into 
it  of  the  blood  from  the  w’ounded  vessel.  This  extravasation  consti¬ 
tutes  a  Traumatic  Aneuriam^  and  may  arise  in  three  wa3^s.  1.  There 
may  be  an  oblique  or  indirect  puncture  into  the  artery,  the  blood  fur¬ 
nished  by  which  partly  escapes  from  the  wound,  pflrtly  extravasates 
itself  into  the  tissues  around  the  vessel.  2.  The  puncture  in  the  integu¬ 
ments  may  have  been  closed  by  plaster  or  bandage ;  and  then  no  blood 
escapes  externall}^,  but,  the  wound  in  the  arteiy  continuing  patent,  the 
blood  is  poured  out  into  the  substance  of  the  limb  or  part.  3.  There 
may  have  been  no  external  wound,  but  the  artery  may  have  been  punc¬ 
tured  or  torn  across  subcutaneously,  by  the  spicula  of  a  fractured  bone, 
b^^  a  violent  strain  or  twist  of  the  limb,  by  the  injury  inflicted  in  a  dis¬ 
location,  or  by  the  Surgeon  in  his  efforts  to  reduce  it. 

These  traumatic  aneurisms,  in  wdiatever  way  arising,  are  of  two  kinds, 
the  Diffused  and  the  Circumscribed. 

DifFased  Traumatic  Aneurism. — This  consists  of  an  eff’usion  of 
blood  poured  out  by,  and  communicating  with,  the  wounded  or  ruptured 
arteiy  ;  limited  in  extent  ly  the  pressure  of  surrounding  parts,  and  par¬ 
tially"  coagulating  in  the  meshes  of  the  broken-down  areolar  tissue.  It 
has  no  sac;  and  its  boundary,  which  is  ill  defined,  is  composed  partly  of 
coagulum,  and  partly  of  plastic  matter  effused  by"  the  tissues  into  which 
it  is  poured  out,  and  has  a  constant  tendency^  to  extend  under  the  pres¬ 
sure  of  the  fluid  blood,  which  continues  to  be  projected  into  the  centre 
of  the  tumor. 

This  form  of  traumatic  aneurism  is  indicated  by"  a  subcutaneous,  soft, 
and  semi-fluctuating  tumor,  often  of  very  considerable  size.  At  first 
the  skin  covering  it  is  of  its  natural  color,  but  it  gradually  becomes 
bluish,  and  is  thinned  by  the  pressure  to  which  it  is  subjected.  If  the 
wound  in  the  vessel  be  rather  large  and  free,  there  will  be  a  distinct 
pulsation  in  the  tumor  sy"nchronous  with  the  beat  of  the  heart,  accom¬ 
panied  by  a  thrilling,  purring,  or  jarring  sensation,  and  often  a  distinct 
and  loud  bruit.  In  other  cases,  if  the  injured  artery  be  small,  or  if  the 
wound  in  it  be  oblique,  and  of  limited  size,  there  may  be  no  distinct 
pulsation  or  bruit  ;  the  tumor  being  either  indolent  and  semi-fluctuating, 
or  having  an  impulse  communicated  to  it  by  the  subjacent  artery.  In 
those  cases  also  in  which  the  artery  is  torn  completely  across,  or  in  which 
the  blood  that  is  effused  coagulates  very  rapidly,  the  ordinary  aneuris- 
mal  bruit  and  pulsation  may  be  very  obscure  or  quite  absent.  In  such 
cases,  the  diagnosis  of  the  true  nature  and  gravity"  of  the  tumor  may 


TREATMENT  OF  TRAUMATIC  ANEURISM. 


271 


usually  be  made  by  observing  that  the  pulse  in  the  arteries  at  a  lower 
point  is  absent,  and  that  there  is  great  oedema  of  the  limb. 

These  tumors,  if  left  to  themselves,  rarely  undergo  spontaneous  cure, 
but  tliey  either  increase  in  size  until  the  integument  covering  them  sloughs 
and  ruptures,  or  the  external  wound,  which  has  been  temporarily  plugged 
by  coagulum,  gives  way;  or  else  they  inflame  and  suppurate,  pointing 
at  last,  like  an  abscess,  and,  on  bursting,  giving  rise  to  a  sudden  gush 
of  blood,  which  may  at  once,  or  by  its  rapid  recurrence,  prove  fatal.  In 
come  cases  a  subcutaneous  breach  is  made  in  the  coagulated  and  plastic 
boundary,  and,  the  blood  becoming  infiltrated  into  the  areolar  tissue, 
syncope,  gangrene,  and  death  follow. 

Treatment _ The  treatment  must  be  conducted  on  precisely  the  same 

2)lan  as  that  of  an  injured  artery  communicating  with  an  external  wound; 
the  only  difference  being  that,  in  the  case  of  the  diffused  traumatic  aneu¬ 
rism,  the  aperture  in  the  artery  opens  into  an  extravasation  of  blood 
instead  of  upon  the  surface.  We  must  especially  be  upon  our  guard 
not  to  be  misled  b}^  the  term  aneurism^  and  not  to  attempt  to  treat  the 
condition,  resulting  from  wound  or  subcutaneous  laceration,  by  the  means 
that  we  employ  with  success  in  the  management  of  aneurism  proper.  In 
a  pathological  aneurism  the  blood  is  contained  within  a  sac,  which,  as 
will  hereafter  be  shown,  is  essential  for  the  process  of  cure  of  the  disease. 
In  the  diffused  traumatic  aneurism  there  is  no  sac,  properly  speaking; 
and  hence  these  changes  to  which  a  sac  is  necessary  cannot  take  place. 
I  doubt  whether  there  is  a  case  on  record  in  which  the  Hunterian  ope¬ 
ration  for  aneurism,  applied  to  the  condition  now  under  consideration, 
has  not  terminated  in  danger  or  death  to  the  patient,  and  in  grievous 
disappointment  to  the  Surgeon. 

The  proper  treatment  of  diffused  traumatic  aneurism  consists  in  Ijdng 
open  the  tumor  by  a  stroke  of  the  scalpel,  removing  the  coagula,  dis¬ 
secting  or  rather  clearing  out  the  artery,  and  ligaturing  it  above  and 
below  the  wound  in  it.  This  operation,  easy  in  description,  is  most  dif¬ 
ficult  and  tedious  in  practice.  The  bleeding  is  often  profuse  ;  the  cavity 
that  is  laid  open  is  large,  ragged,  and  partially  filled  with  coagula ;  it  is 
often  with  much  difficult}'  that  the  artery  is  found  under  cover  of  these, 
and  in  the  midst  of  infiltrated  and  disorganized  tissues;  and  when  it  is 
found,  it  is  not  always  easy  to  get  a  ligature  to  hold.  It  will  be  conve¬ 
nient  to  divide  this  operation  into  two  stages:  I.  Exposing  the  artery; 
2.  Passing  the  ligature. 

Firat  Stage. — The  artery  must,  if  at  all  practicable,  be  thoroughly 
compressed  between  the  tumor  and  the  heart  by  a  tourniquet,  or  by  the 
hand  of  an  assistant.  If  it  can  be  so  commanded,  the  diffused  aneurism 

t 

may  be  at  once  and  freely  laid  open;  but  if  not,  the  Surgeon  must 
proceed  more  cautiously.  He  must  make  a  small  aperture  in  the  most 
prominent  part  of  the  tumour,  and  introduce  two  of  the  fingers  of  the 
left  hand  so  as  to  plug  the  wound  in  the  integuments,  and  prevent  the 
escape  of  blood  by  it,  at  the  same  time  feeling  for  the  opening  in  the 
artery,  and  pressing  his  finger  well  upon  this.  Having  ascertained  that 
he  controls  the  vessel  thoroughly  by  the  pressure  of  his  left  index  and 
middle  fingers,  he  ma}'  proceed  to  slit  open  the  wound  in  the  integuments, 
and  clear  the  clots  and  blood  thoroughly  out  of  the  aneurismal  tumor. 

Second  Stage _ The  Surgeon  will  now  have  exposed  the  posterior  part 

of  the  aneurismal  cavity.  But  the  artery  is  not  ^^et  cleared  for  the 
application  of  the  ligature.  If  the  artery  above  be  commanded  by 
pressure,  and  there  be  no  immediate  danger  of  hemorrhage,  this  may 
best  be  done  by  passing  a  steel  probe,  or,  what  is  better,  a  full-sized 


272 


TRAUMATIC  ANEURISM. 


bougie,  or  a  sound  into  the  open  wound  in  the  artery  so  as  to  distend 
the  vessel,  dissecting  down  on  each  side  of  this  through  the  posterior 
wall  of  the  sac,  and  then  passing  the  ligature  in  the  usual  way.  But  if 
the  vessel  be  so  near  the  centre  of  the  circulation  that  it  cannot  be 
efficiently  commanded,  then  the  difficulties  become  far  greater,  for  the 
Surgeon  must  on  no  account  remove  his  finger  for  an  instant  from  the 
open  wound;  but,  keeping  it  firmly  and  securel3^  pressed  into  this,  he 
must  endeavor,  by  scratching  through  the  tissues  above  it,  to  expose 
the  artery  sufficient!}"  to  make  a  dip  with  the  needle  round  it,  and  thus 
to  secure  it.  This  part  of  the  operation  is  by  far  the  most  difficult  in 
such  cases,  on  account  of  the  infiltration  of  the  parts  and  the  thickening 
of  the  structures  preventing  the  artery  from  being  readily  distinguished 
and  easily  cleared. 

The  application  of  a  ligature  to  the  distal  end  of  the  vessel,  if  it  be 
completeh^  divided,  is  especiall}^  difficult.  Should  it  not  be  practicable, 
the  application  of  the  actual  cautery,  or  pressure  by  means  of  a  sponge- 
tent  or  graduated  compress,  will  be  found  the  best  means  of  arresting 
the  hemorrhage. 


Circumscribed  Traumatic  Aneurism  differs  entirely  from  the 
diffused  in  its  pathology  and  treatment,  inasmuch  as  it  possesses  a 
distinct  sac.  Tliere  are  two  varieties  of  this  form  of  aneurism. 

1.  In  the  first  variet}",  a  puncture  is  made  in  an  artery,  or  the  vessel 
is  ruptured  subcutaneously,  as  perhaps  in  the  reduction  of  an  old  dis¬ 
location;  blood  is  extravasated  into  the  adjoining  tissues;  and,  if  there 
be  an  external  aperture,  this  cicatrizes.  The  blood  that  is  extravasated 
becomes  surrounded  and  limited  by  a  dense  layer  of  plastic  matter, 
forming  a  distinct  circumscribed  sac,  which  is  soon  lined  b}^  layers  of 
fibrine  deposited  from  the  blood  that  passes  through  it.  This  tumor, 
usually  of  moderate  size,  and  of  tolerably  firm  consistence,  pulsates  syn¬ 
chronously  with  the  beat  of  the  heart,  and  has  a  distinct  bruit,  both  of 
which  cease  when  the  artery  leading  to  it  is  compressed.  This  form  of  cir¬ 
cumscribed  traumatic  aneurism  most  commonly  occurs  from  punctured 
wounds  of  small  arteries,  as  the  temporal,  plantar,  palmar,  radial,  and  ulnar. 

The  treatment  to  be  adopted  depends  upon  the  size  and  situation  of 
the  artery  with  which  the  tumor  is  connected.  If  the  arteiy  be  small, 

and  so  situated  that  it  can  be  opened  without 
112.  much  subsequent  inconvenience  to  the  patient, 

as  on  the  temple  or  in  the  forearm,  it  should  be 
laid  open,  the  coagula  turned  out,  and  the  ves¬ 
sel  ligatured  above  and  below  the  wound  in  it. 
If  the  tumor  be  so  situated,  as  in  the  palm, 
that  it  would  be  difficult  and  hazardous  to  the 
integrity  of  the  patient’s  hand  to  lay  it  open, 
the  Hunterian  operation  for  aneurism  should 
be  performed,  as  was  successfully  done  in  a 
case  (Fig.  112)  in  which  the  brachial  was  liga¬ 
tured  for  an  aneurism  of  this  kind  in  the  ball 


Fig. 


of  the  thumb, 


following  serious 


injury  to  the 


rism  in  Ball  of  Thumb  after  a 
Powder-flask  explosion. 


hand  from  a  powder-flask  explosion.  When  it 
is  connected  with  the  superficial  palmer  arch 
I  have,  however,  successfully  adopted  the  old 
operation  of  laying  the  tumor  open,  taking 
out  coagula,  and  ligaturing  the  artery  at  the 
seat  of  injury. 

It  is  but  rarely  that  this  form  of  traumatic 


ARTERIO-VENOUS  WOUNDS. 


273 


aneurism  is  connected  with  a  large  artery ;  when  it  is,  the  vessel  may  be 
ligatured  above,  but  close  to  the  sac,  in  the  same  wa}"  as  in  the  next 
variety.  If  this  form  of  traumatic  aneurism  have  increased  greatly  in 
bulk,  so  that  the  skin  becomes  thin  and  discolored,  or  if  inflammation 
ensue,  and  s3'mptoms  of  impending  suppuration  take  place  around  it, 
then  it  would  be  useless  to  ligature  the  arteiy  above  the  tumor,  as  this 
would  certainly"  give  waj",  and  secondaiy  hemorrhage  follow.  Here  the 
proper  course  is  to  lay  open  the  sac,  turn  out  the  contents,  and  tie  the 
artery  above  and  below  the  part  that  is  wounded. 

2.  The  next  form  of  circumscribed  traumatic  aneurism  is  of  rare  oc¬ 
currence,  and  usuall}^  arises  from  a  small  puncture  in  a  large  arteiy,  as 
the  axillary  or  the  carotid.  This  bleeds  freely ;  but,  the  hemorrhage 
being  arrested  b}^  pressure,  the  external  wound  and  that  in  the  arteiy 
close.  The  cicatrix  in  the  arterj’  gradiiall}^  3'ields,  forming,  at  the  end 
of  weeks  or  months,  a  tumor  which  enlarges,  dilates,  and  pulsates 
eccentricall3",  with  distinct  bruit,  having  all  the  S3’mptoms  that  charac¬ 
terize  an  aneurism  from  disease,  and  having  a  sac  formed  bv  the  outer 
coat  and  sheath  of  the  vessel.  It  is  at  first  soft  and  compressible  on 
being  squeezed,  but  becomes  harder  and  firmer,  and  cannot  be  so  les¬ 
sened  after  a  time.  It  consists  of  a  distinct  circumscribed  sac,  formed  by 
the  dilatation  of  the  cicatrix  in  the  external  coat  and  sheath  of  the 
arteiy,  no  blood  being  efl[*used  into  the  surrounding  tissues. 

The  Treatment  will  vaiy  according  to  the  size  of  the  tumor.  If  this 
be  small  or  but  moderate  in  size,  it  consists  in  the  ligature  or  compres¬ 
sion  of  the  arteiy  leading  to  the  sac,  in  accordance  with  the  principles 
that  guide  us  in  the  treatment  of  aneurism  from  disease ;  thougli,  from 
the  healtly^  state  of  the  coats  of  the  vessel,  the  arteiy  may  be  ligatured 
as  near  as  possible  to  the  sac. 

As  there  is  a  distinct  C3^st  or  sac  in  these  circumscribed  aneurisms, 
the  changes  that  will  be  described  in  the  chapter  on  the  Treatment  of 
Aneurisms  in  general  take  place;  the  tumor  gradually  becoming  con¬ 
solidated,  and  eventuall3’'  absorbed.  Should,  however,  the  aneurism 
have  attained  an  enormous  magnitude,  or  should  it,  from  being  circum¬ 
scribed,  have  become  diffused  133^  the  rupture  of  the  sac,  then  the  tumor 
must  be  laid  freel3’  open,  the  coagula  turned  out,  and  the  arteiy  ligatured 
as  in  the  ordinar3"  diffused  aneurism. 

ARTERIO-VENOUS  WOUNDS. 

A  wound  in  an  arter3"  may  communicate  with  a  corresponding  one 
in  a  contiguous  vein,  giving  rise  to  two  distinct  forms  of  disease — Aneu- 
rismal  Varix  and  Varicose  Aneurism.  These  preternatural  communi¬ 
cations,  which  were  first  noticed  and  accuratel3"  described  133"  W.  Hunter, 
most  commonly  happen  at  the  bend  of  the  arm,  as  a  consequence  of  the 
puncture  of  the  brachial  artery  in  bleeding;  but  the3"  have  been  met 
with  in  eveiy  part  of  the  body  in  which  an  arter3’'  and  vein  lie  in  close 
juxtaposition,  having  been  found  to  occur  as  a  consequence  of  wounds 
of  the  subclavian,  radial,  carotid,  temporal,  iliac,  femoral,  popliteal,  and 
tibial  arteries.  The  two  forms  of  disease  to  which  tlie  preternatural 
communication  between  arteries  and  veins  gives  rise,  differ  so  completely 
in  their  nature,  s3’mptoms,  effects,  and  treatment,  that  separate  con¬ 
sideration  of  each  is  required. 

Aneurismal  Varix  results  when,  a  contiguous  artery  and  vein 
having  been  perforated,  adhesion  takes  place  between  the  two  vessels  at 
the  seat  of  injuiy,  the  communication  between  them  continuing  pervious, 
VOL.  I. — 18 


274 


ARTERIO-VENOUS  WOUNDS. 


and  a  portion  of  the  arterial  blood  being  projected  directly  into  the  vein 
at  each  beat  of  the  pulse.  Opposite  to  the  aperture  of  communication 
between  the  two  vessels,  wdiich  is  alwaj's  rounded  and  smooth,  tlie  vein 
will  be  found  to  be  dilated  into  a  fusiform  pouch,  with  thickened  coats. 
The  veins  of  the  part  generally  are  considerably  enlarged,  somewhat 
nodulated,  tortuous,  and  thickened.  The  artery  above  the  wound  is 
dilated;  below,  it  is  usually  somewhat  contracted.  These  pathological 
conditions  are  evidentl}^  referable  to  a  certain  quantity  of  the  arterial 
blood  finding  its  way  into  the  vein,  and  distending  and  irritating  it  by 
its  pressure  and  presence,  and  less  consequently  being  conveyed  by  the 
lower  portion  of  the  artery. 

The  Symptoms  consist  of  a  tumor  at  the  seat  of  injury,  wdiich  can  be 
emptied  by  pressure  upon  the  artery  leading  to  it,  or  by  compressing 
its  walls.  If  subcutaneous^  this  tumor  is  of  a  blue  or  purple  color,  of 
an  oblong  shape,  and  will  be  seen  to  receive  the  dilated  and  tortuous 
veins.  It  will  be  found  to  pulsate  distinctly  with  a  tremulous  jarring 
motion,  rather  than  a  distinct  impulse.  Auscultation  detects  in  it  a 
loud  and  blowing,  wdiiffing,  rasping,  or  hissing  sound,  usually  of  a  pecu¬ 
liarly  harsh  character.  This  sound  has  very  aptly  been  compared  by 
Porter  to  the  noise  made  by  a  fly  in  a  paper-bag,  and  by  Liston  to  the 
sound  of  distant  and  complicated  machinery.  The  thrill  and  sound  are 
more  distinct  in  the  upper  than  in  the  lower  part  of  the  limb,  and  are 
most  perceptible  if  it  be  allowed  to  hang  down  so  as  to  become  con¬ 
gested.  Besides  these  local  symptoms,  there  are  usually  some  muscular 
weakness,  and  diminution  in  the  temperature  of  the  part  supplied  by  the 
injured  artery. 

Treatment. — As  this  condition,  when  once  formed,  is  stationary,  all 
operative  interference  should  be  avoided,  an  elastic  bandage  merely 
being  applied.  Should  a  case  occur  in  which  more  than  this  is  re¬ 
quired,  the  artery  must  be  cut  down  upon  and  ligatured  on  each  side 
of  the  wound  in  it. 

Varicose  Aneurism. — In  this  case  the  openings  in  the  artery  and 
vein  do  not  directly  communicate  (see  Figs.  114  and  115),  but  an  aneu- 
rismal  sac  is  formed  between  the  two  vessels,  into  which  the  blood  is 
poured  before  passing  into  the  vein. 


Fig.  113. 


A  Varicose  Aneurism  at  the  Bend  of  the  Arm  unopened. 


The  Pathological  Condition  of  this  form  of  injury  consists  in  the  forma¬ 
tion  of  a  circumscribed  false  aneurism,  communicating  on  one  side  with 
the  artery,  and  on  the  other  with  the  vein,  which  is  always  in  a  state  of 
varix.  A  varicose  aneurism  is,  in  fact,  a  circumscribed  traumatic 
aneurism  plus  an  aneurismal  varix.  This  condition  is  well  represented 


VARICOSE  ANEURISM. 


275 


in  the  annexed  cuts,  from  drawings  of  Sir  C.  Bell’s,  in  the  Museum  of 
University  College,  representing  a  varicose  aneurism  before  and  after  it 
had  been  opened  (Figs.  113  to  116.)  In  this  case  there  appears  to  have 


Fig.  114. 


The  same  Varicose  Aneurism  removed  from  its  Connections. 


been  a  high  division  of  the  brachial,  and  a  communicating  branch  below' 
the  wound,  between  the  radial  and  ulnar;  in  consequence  of  which,  as 
Mr.  Shaw  informs  me,  the  tumor  pulsated  as  forcibly  after  the  operation 
as  before,  and,  the  blood  finding  its  way  back  through  the  aneurism  into 
the  veins,  gangrene  of  the  hand  and  arm  w  as  produced. 

Symptoms. — In  the  symptoms  of  varicose  aneurism,  we  have  a  combi¬ 
nation  of  the  characters  of  aneurismal  varix  and  of  the  circumscribed 
traumatic  aneurism  ;  there  is  a  pulsating  tumor,  at  first  soft  and  com¬ 
pressible,  but,  after  a  time,  assuming  a  more  solid  consistence,  in  conse¬ 
quence  of  the  deposition  of  fibrine  within  it:  above  this  tumor,  the  vein 


Fig.  115. 


The  same  Tumor  laid  open,  showing  the  Circumscribed  False  Aneurism  between  the  two  Vessels. 


that  has  been  punctured  is  dilated  into  a  fusiform  pouch,  presenting  the 
ordinary  characters  of  varix.  The  sounds  heard  in  these  tumors  are  of 
two  distinct  kinds;  there  is  the  peculiar  buzzing  thrill  that  always  exists 
where  there  is  a  preternatural  communication  between  an  artery  and 
vein;  besides  this,  there  is  a  blowing  or  bellows  sound,  dependent  on 
the  aneurismal  disease.  These  signs  are  most  perceptible  when  the 
limb  is  in  a  dependent  position;  and  the  sounds  can  often  be  heard  in 
the  veins  at  a  considerable  distance  from  the  seat  of  injury.  There  is 
also  some  impairment  in  the  nutrition  and  temperature  of  the  parts  sup¬ 
plied  by  the  injured  vessels.  As  the  disease  advances,  the  aneurismal 
tumor  lying  between  the  artery  and  vein  continues  to  increase  in  size, 
and  to  become  hardened  by  the  deposition  of  laminated  fibrine.  If  left 
to  itself,  it  would  probably  continue  to  enlarge  until  sloughing  of  the 
integuments  covering  it,  followed  by  hemorrhage,  took  place.  In  some 
cases,  the  aperture  of  communication  between  the  vein  and  sac  becomes 
closed,  and  the  aneurism  is  converted  into  one  of  the  false  circumscribed 
variety. 


276 


WOUNDS  OF  SPECIAL  BLOODVESSELS. 


Treatment. — The  treatment  of  this  disease  must  he  conducted  on  dif¬ 
ferent  principles  from  those  that  have  been  laid  down  as  required  in  the 
ordinary  circumscribed  traumatic  aneurism  ;  the  difference  depending 
upon  the  fact,  that  in  the  varicose  aneurism  there  is  always  a  double 
aperture  in  the  sac,  and  that  thus  the  proper  deposition  of  laminated 
fibrine  necessaiy  for  its  occlusion  cannot  take  place.  The  sac  of  such 
an  aneurism  may  be  compared  to  one  that  has  been  ruptured,  or  acci¬ 
dentally  opened,  in  which  w^e  could  consequently  not  expect  the  occur¬ 
rence  of  those  changes  that  are  necessary  for  the  cure  of  aneurism  by 
the  Hunterian  operation. 

In  a  varicose  aneurism,  consequently,  the  sac  must  be  freely  incised, 
and  the  artery  tied  on  each  side  of  the  puncture  in  it.  This  procedure 


ma3’,  unless  the  Surgeon  be 
careful,  and  properly  under¬ 
stand  the  patholog}^  of  this 
disease,  be  attended  by  some 
difficulty  (Fig.  116).  After 


Fig. 116. 


the  first  incision  has  been 
made  through  the  integu- 
ments,  the  dilated  vein  will 
be  laid  open,  and  an  aperture 
will  be  seen  at  the  bottom  of 
the  vessel,  from  which  arterial 
blood  may  be  made  to  issue. 
If  an  attempt  be  made  to  find 
the  artery  immediately^  below 
this  aperture,  the  Surgeon 
will  be  disappointed,  for  the 


sac  of  the  circumscribed  aneurism  intervenes  between  the  tw’o  vessels. 
That  this  aperture  leads  into  the  sac,  and  not  into  the  artery,  may 
readiW  be  ascertained  by^  introducing  a  probe  into  it,  which  wdll  be  seen 
to  be  capable  of  being  carried  sidew’ays,  as  well  as  upwards  arrd  down¬ 
wards,  to  a  corrsiderable  extent,  and  in  different  directions  altogether 
out  of  the  course  of  the  artery.  In  order  to  expose  this  vessel  properly, 
a  probe-pointed  bistoury  must  be  introduced  into  this  opening,  and  the 
sac  of  the  false  aneurism  slit  up  to  its  full  extent,  the  coagula  turned 
out,  and  the  puncture  in  the  artery  sought  for  in  the  bottom  of  the 
cavity  that  has  been  exposed ;  this  may  now^  readily  be  made  visible 
by  the  escape  of  a  jet  of  arterial  blood  on  relaxing  the  pressure  on  the 
upper  part  of  the  artery ;  a  ligature  must  then  be  passed  above  and 
below  the  wound,  and  the  cavity  lightly  dressed  with  lint. 


CHAPTER  XVI. 


WOUNDS  OF  SPECIAL  BLOODVESSELS. 


Vessels  of  the  Head  and  Neck. — Wounds  of  the  Carotid  Artery^ 
and  of  its  primary  and  secondary  divisions,  are  of  more  frequent  occur¬ 
rence  in  civil  practice  tharr  similar  injuries  of  any  other  set  of  arteries  in 
the  body,  in  consequence  of  the  rreck  being  frequently  the  seat  of  suici¬ 
dal  attempts.  The  hemorrhage  from  wounds  of  the  main  trunk  is  so  copi- 


VESSELS  OF  THE  UPPER  LIMB. 


277 


ous  as  often  to  be  immediately  fatal.  In  the  event  of  a  Surgeon  being 
at  hand,  both  ends  of  the  bleeding  vessel  must  be  at  once  ligatured. 
Should  the  hemorrhage,  whether  primary  or  secondary,  proceed  from  a 
deep  branch,  as  the  internal  maxillary,  deep  temporal,  or  internal  carotid, 
so  situated  as  not  to  admit  of  the  vessel  being  exposed  and  ligatured  at 
the  seat  of  wound,  the  ordinary  rule  of  practice  of  tying  a  wounded 
artery  at  the  seat  of  injury  must  be  departed  from,  and  the  common 
carotid  tied  in  the  neck. 

In  consequence  of  the  speedy  fatality  of  the  wounds  of  the  carotid 
artery  and  its  branches.  Traumatic  Aneurisms  are  rarely  met  with  in 
this  situation ;  they  do,  however,  occasionally  occur,  and  the  records  of 
surgery  contain  at  least  six  instances  of  the  kind,  in  each  of  which  the 
common  carotid  was  tied,  and  the  patient  ultimately  recovered. 

Aneurismal  Varix  in  the  Nech^  dependent  on  puncture  of  the  Inter¬ 
nal  Jugular  Vein  and  Carotid  Artery^  usually  the  result  of  sword- 
thrusts,  is  apparently  of  more  frequent  occurrence  than  traumatic  aneu¬ 
rism  in  this  region;  probably  owing  to  the  close  proximity  of  the  vein 
renderino;  it  difficult  for  the  arterv  to  be  wounded  on  the  outer  or  ante- 
rior  sides,  without  first  perforating  that  vessel.  The  symptoms  offer  the 
general  characteristics  of  aneurismal  varix,  but  have  several  points  that 
are  worthy  of  special  remark.  The  wound  of  the  vessels  has  been  in 
every  instance  followed  by  the  effusion  of  a  large  quantity^of  blood  into 
the  loose  areolar  tissue  of  the  neck ;  the  extravasation  acquiring  even 
the  size  of  a  child’s  head,  and  threatening  immediate  suffocation.  As 
this  extravasation  subsided,  the  ordinary  characters  of  aneurismal  varix 
began  to  manifest  themselves.  The  period  at  which  these  symptoms 
first  made  their  appearance  varied  somewhat  in  the  different  cases,  but 
they  always  occurred  within  four  or  five  days  of  the  receipt  of  the  injury. 
In  none  of  the  cases  did  the  disease  appear  to  shorten  life,  or  to  occasion 
any  dangerous  or  inconvenient  effects,  with  the  exception  of  some  diffi¬ 
culty  in  lying  on  the  affected  side,  and  occasionally  giddiness  or  noise 
in  the  head  on  stooping.  No  operation  is  admissible  in  these  affections. 

Varicose  Aneurism  does  not  appear  to  have  been  met  with  in  this 
situation. 

Traumatic  Aneurism  of  the  Temporal  Artery^  and  of  its  branches, 
occasionally  occurs  as  the  result  of  partial  division  of  tliese  vessels  in 
cupping  on  the  temple.  I  have  met  with  two  cases  of  this  kind,  in  both 
of  which  the  disease  was  readily  cured  by  laying  the  tumor  open,  turning 
out  its  contents,  and  tying  the  artery  on  each  side  of  it. 

Hemorrhage  from  the  Deep  Arteries  of  the  Face^  as  in  gunshot  inju¬ 
ries,  if  too  copious  to  be  restrained  by  cold,  requires  the  ligature  of  the 
common  or  external  carotid. 

Vessels  of  the  Upper  Limb. — A  Wound  of  the  Subclavian  Artery 
may  almost  invariabl}^  be  looked  upon  as  fatal ;  though,  in  consequence 
of  the  manner  in  which  the  vessel  is  protected  by  the  clavicle,  this  injury 
can  scarcely  occur  except  from  gunshot  violence.  From  the  rapidly 
fatal  nature  of  wounds  of  the  subclavian  arteiy.  Traumatic  Aneurisms 
in  this  situation  are  not  met  with  ;  but  wdiere  the  artery  passes  into  the 
axilla  below  the  margin  of  the  first  rib,  they  are  not  unfrequent. 

Aneurismal  Varix^  resulting  from  wound  of  the  Subclavian  Artery 
and  Vein^  has  been  seen,  notwithstanding  the  separation  that  exists  be¬ 
tween  the  two  vessels  until  they  reach  the  acromial  angle  of  the  subcla¬ 
vian  space.  These  injuries  have  likewise  usually  been  the  result  of 
sword-thrusts,  and  do  not  admit  of  any  surgical  interference. 

In  Open  Wounds  of  the  Axillary  Artery  and  of  its  Branches^  the  rule 


278 


WOUNDS  OF  SPECIAL  BLOODVESSELS. 


of  practice  consists  in  cutting  down  upon  the  bleeding  vessel  and  liga¬ 
turing  it  on  each  side  of  the  wound.  It  must  be  borne  in  mind  that, 
the  arterial  branches  given  off  between  the  lower  edge  of  the  first  rib 
and  the  fold  of  the  axilla  being  veiy  numerous,  a  punctured  wound  of 
the  axilla  or  side  of  the  chest  may  injure  one  of  these  vessels;  though  from 
its  course,  and  the  free  flow  of  arterial  blood  that  has  followed  the  stab, 
it  may  be  supposed  that  the  axillary  artery  itself  has  been  punctured. 
The  particular  vessel  injured  can  only  be  ascertained  by  following  up 
the  wound,  and  ligaturing  the  arteiy  that  furnishes  the  blood. 

In  some  cases,  however,  the  state  of  the  parts  may  be  such,  that  it 
may  be  impossible  to  trace  the  artery  at  the  depth  at  which  it  is  situated, 
or  even  to  expose  it  in  a  mere  superficial  situation,  as  in  the  stump  after 
amputation  at  the  shoulder-joint.  In  these  circumstances,  the  rule  of 
ligaturing  an  artery  at  the  seat  of  injury  maybe  departed  from,  and  the 
main  trunk  should  be  tied  either  above  or  below  the  clavicle ;  and  the 
success  of  this  operation  has  been  sufficient  to  justify  our  having 
recourse  to  it,  rather  than  exhaust  the  patient  by  any  prolonged  attempts 
at  the  ligature  of  the  vessel  in  the  open  wound,  though  I  think  that  this 
ought  first  to  be  attempted.  Of  15  cases  in  which  the  artery  has  been 
ligatured  either  above  or  below  the  clavicle,  for  hemorrhage  from  wounds 
•in  the  axilla  or  from  stumps,  I  find  that  9  were  cured  and  6  died. 
Although  the  success  is  about  equal  in  whichever  situation  the  vessel  be 
tied,  I  should  certainly  give  the  preference  to  the  supraclavicular  ope¬ 
ration,  owing  to  the  greater  facility  of  its  performance,  and  the  com¬ 
parative  absence  of  collateral  branches  at  the  seat  of  ligature.  In  some 
cases,  however,  especially  after  amputations  at  the  shoulder,  the  clavicle 
is  pushed  up  at  its  acromial  end,  and  then  the  artery  might  be  best 
reached  below  the  clavicle,  under  or  through  the  pectoral  muscles. 

Traumatic  Aneurism  of  the  Axilla  is  not  of  unfrequent  occurrence, 
arising  directl}^  from  gunshot  wounds,  or  from  the  thrust  of  a  knife, 
sabre,  or  other  pointed  weapon.  In  some  cases  the  injury  arises  from  a 
subcutaneous  rupture  of  the  vessel,  the  patient  stretching  out  and  strain¬ 
ing  his  arm  in  an  attempt  to  save  himself  from  falling,  and  feeling  a 
sudden  snap  in  the  axilla,  which  is  followed  by  the  formation  of  a  rapidly 
diffused  aneurism. 

There  are  several  cases  on  record  in  which  axillary  aneurism  has 
resulted  from  violent  attempts  made  bj^the  Surgeon  in  the  reduction  of 
old-standino;  dislocations  of  the  head  of  the  humerus.  Thus  Pelletan 
mentions  a  case  of  this  kind,  in  which  the  tumor,  being  supposed  to  be 
emphysematous,  was  opened,  and  the  patient  perished  of  hemorrhage. 
Warren  relates  a  case  of  diffused  axillary  aneurism  resulting  from  rup¬ 
ture  of  the  artery,  in  consequence  of  the  Surgeon  attempting  to  reduce 
a  dislocation  of  the  humerus  by  using  his  foot  as  a  fulcrum  in  the  axilla, 
but  without  taking  off  his  boot.  Gibson  has  related  three  cases  of 
axillary  aneurism  following  rupture  of  the  artery,  in  the  attempt  to 
reduce  old-standing  dislocations  with  the  pulleys.  These  cases  are  of 
much  interest  to  the  Surgeon,  as  showing  the  necessity  for  great  caution 
in  the  use  of  powerful  extending  force  in  the  reduction  of  old  disloca¬ 
tions,  adhesions  having  probably  formed  between  the  artery  and  head 
of  the  bone. 

In  those  cases  of  diffused  traumatic  aneurism  of  the  axilla  that  arise 
from  subcutaneous  rupture  or  laceration  of  the  artery,  the  condition  of 
parts  is  essentially  the  same  as  in  the  case  of  an  open  wound  of  the 
vessel,  with  the  exception  of  the  absence  of  any  external  aperture  in 
the  integuments.  In  these  cases  a  tumor  of  considerable  size,  hard  or 


f 


TRAUMATIC  AXILLARY  ANEURISM.  279 

fluctuating,  according  to  the  state  of  coagulation  of  its  contents,  will 
form  with  more  or  less  rapidity.  If  it  have  formed  very  quickly,  the 
artery  being  torn  across,  and  the  blood  coagulating  as  it  is  effused,  it 
will  not  present  the  ordinaiy  aneurismal  signs,  but  maj^  merely  resemble 
an  ordinary  extravasation  ;  from  this,  however,  it  may  be  distinguished 
by  the  loss  of  the  pulse  at  the  wrist,  and  by  the  oedema  of  the  arm.  If 
it  form  slowly,  the  blood  continuing  fluid,  there  will  be  the  usual  signs 
of  aneurism,  such  as  thrill,  pulsation,  and  a  gushing  hot  sensation.  In 
all  these  cases,  there  is  much  oedema  of  the  arm,  with  a  tendency  to 
inflammation,  suppuration,  and  sloughing  of  the  tumor,  and  the  parts 
amongst  which  it  lies,  with  perhaps  gangrene  of  the  limb  itself. 

Some  of  these  traumatic  axillary  aneurisms  have  a  tendencv  to  diffuse 
themselves  with  great  rapidity,  filling  up  the  whole  of  the  hollow  of  the 
armpit,  and  extending  under  the  pectorals,  even  up  around  the  shoulder. 
In  other  cases  again,  when  more  circumscribed,  the  disease  ma^’’  get  well 
spontaneously,  as  happened  in  cases  recorded  by  Van  Sweden,  Sabatier, 
and  Hodgson.  In  other  instances  again,  the  disease  has  remained  sta¬ 
tionary  for  3’ears,  or  has  even  undergone  consolidation  under  medical 
treatment.  It  cannot,  however,  be  considered  sound  practice  to  leave  a 
traumatic  aneurism  of  this  arterj^  without  surgical  interference,  after 
the  ordinaiy  dietetic  and  lygienic  plans  of  treatment  have  failed  in 
effecting  a  cure,  for  it  ma^^  at  any  time  become  rapidly  diffused,  or 
inflame  and  suppurate. 

The  Treatment  of  traumatic  axillary  aneurism  must  depend  not  only 
on  the  question  whether  it  be  diffused  or  circumscribed  ;  but,  if  diffused, 
whether  it  be  of  recent  origin,  or  have  originated  from  puncture  or  from 
subcutaneous  rupture  or  laceration  of  the  vessel  as  a  consequence  of 
dislocation,  fracture,  blow,  or  strain. 

When  a  diffused  traumatic  aneurism  of  recent  origin,  rapid  formation, 
and  dependent  upon  puncture  of  the  arteiy,  is  met  with  in  the  axilla,  the 
treatment  must  be  conducted  in  the  same  wa}^  as  that  of  a  wounded 
arteiy,  without  extravasation,  in  this  situation.  As  Guthrie  veiy  justly 
observes,  it  can  make  no  difference  whether  the  puncture  in  the  skin 
have  healed  or  not — the  condition  of  the  artery  must  be  the  same.  The 
tumor  should  be  laid  open,  the  coagula  turned  out,  the  arteiy  sought  for, 
and  ligatured  where  wounded.  There  is,  however,  danger  after  this 
operation,  either  of  secondaiy  hemorrhage  coming  on  from  the  seat  of 
wound,  by  blood  conveyed  through  the  collateral  vessels  which  open 
into  the  subscapular  and  circumflex  arteries;  or  else  of  the  limb  falling 
into  a  state  of  gangrene.  In  either  case,  amputation  of  the  shoulder 
and  through  the  aneurismal  extravasation  is  the  onl^"  practice  that  holds 
out  a  chance  of  life  to  the  patient. 

In  diffused  traumatic  aneurism  of  the  axilla  from  subcutaneous  rup¬ 
ture  or  laceration  of  the  axillary  artery,  the  choice  would  lie  between 
treating  the  injuiy  by  direct  incision,  and  ligaturing  the  vessel  above  the 
clavicle.  The  ligature  of  the  vessel  above  the  clavicle  has  been  done 
three  times,  with  onl}’’  one  recoveiy,  two  of  the  patients  d\dng  of  gan¬ 
grene  and  secondaiy  hemorrhage.  In  the  successful  case,  secondar^^ 
hemorrhage  had  occurred;  and  gangrene  of  the  arm,  which  threatened, 
was  prevented,  and  the  patient  saved,  ly^'  amputation  at  the  shoulder- 
joint.  The  result,  therefore,  of  ligature  is  so  little  promising,  that  few 
Surgeons  would  be  disposed,  in  the  face  of  these  facts,  to  repeat  this 
operation. 

The  only  other  alternative  consists  in  treating  the  ruptured  artery  on 
the  same  principle  as  a  wounded  one,  disregarding  the  accidental  com- 


280 


WOUNDS  OF  SPECIAL  BLOODVESSELS. 


plication  of  the  subcutaneous  accumulation  of  a  few  ounces  or  pounds 
of  blood.  This  undoubtedly  is  the  proper  surgical  princiiDle  on  which 
to  act  in  these  cases.  Its  adoption  has  been  strongly  urged  by  Guthrie, 
and  its  advantage  has  been  demonstrated  by  the  success  attending  it  in 
several  cases  in  which  it  has  been  adopted  by  Paget,  Syme,  and  others. 
The  operation  consists  in  compressing  the  subclavian  above  the  clavicle, 
either  by  the  direct  pressure  of  the  finger,  or,  as  was  done  by  Syme  in 
his  case,  by  previously  making  an  incision  over  it,  through  which  it 
could  be  more  readily  commanded ;  then  la3dng  the  tumor  open  by  a 
free  incision  through  the  anterior  fold  of  the  axilla  and  the  pectoral 
muscles,  turning  out  the  coagula,  and  seeking  for  and  ligaturing  the 
arteiy  at  both  ends ;  for  it  must  be  remembered,  that  the  distal  extremitj'" 
of  the  torn  vessel  will  probably  bleed  freel}^,  owing  to  the  open  anasto¬ 
moses  round  the  shoulder. 

Circumscribed  Traumatic  Aneurisms  of  the  Axillary  Artery  are  not 
uncommonly  of  slow  formation,  existing  for  several  months  or  3’ears 
before  they  require  operation,  although  resulting  from  punctured  wound 
of  the  armpit.  In  chronic  cases  of  tliis  kind,  the  aneurism  is  necessarily 
provided  with  a  firm  and  distinct  sac,  and  approaches  closely  in  its 
characters  to  the  pathological  form  of  the  disease. 

The  Treatment  here  cannot  be  conducted  on  the  principles  that  guide 
us  in  the  management  of  a  wound,  or  of  a  diffused  aneurism  of  recent 
occurrence  of  this  artery ;  for  not  only  is  the  circumscribed  aneurism 
provided  with  a  sac,  but  the  vessel  at  the  point  injured  will  very  probably 
be  found  to  have  undergone  changes  that  render  it  little  able  to  admit 
or  to  bear  the  application  of  the  ligature.  It  will  be  softened,  thick¬ 
ened,  and  lacerable,  with  perhaps  a  wide  funnel-shaped  aperture  leading 
into  the  sac,  which  will  be  closely  incorporated  with  the  neighboring 
parts.  But,  indeed,  the  treatment  of  this  form  of  circumscribed  trau¬ 
matic  aneurism  by  the  ligature  of  the  arteiy  on  the  proximal  side  of  the 
sac,  has  been  found  to  be  attended  with  remarkable  success.  In  eight 
recorded  cases  in  which  this  operation  has  been  performed,  not  one  fatal 
result  has  been  noted.  In  all,  the  aneurism  arose  from  stabs  or  gunshot 
wounds,  and  had  existed  for  various  periods,  between  two  weeks  and 
four  3’ears.  In  four  of  the  cases  the  arteiy  was  ligatured  above,  and  in 
four  below  the  clavicle;  and  in  one  case  of  each  category  there  was  sup¬ 
puration  of  the  sac. 

The  particular  point  at  which  the  arteiy  should  be  ligatured  must 
depend  upon  the  condition  of  the  tumor.  If  this  be  of  large  size,  or 
arise  from  the  upper  part  of  the  axillary  artery  above  or  immediately 
below  tlie  pectoralis  minor  muscle,  there  is  no  choice  but  to  deligate  the 
vessel  above  the  clavicle.  Should,  however,  the  principal  increase  in  the 
tumor  take  place  in  a  direction  downwards  and  forwards  under  the  great 
pectoral  muscle,  the  portion  of  the  artery  immediate!}^  below  the  clavicle 
appearing  to  be  free  from  disease,  the  question  would  arise  as  to  whether 
this  part  might  not  be  selected  for  the  application  of  the  ligature ;  and, 
as  the  results  of  both  operations  have  hitherto  been  equally  favorable, 
this  must  rather  be  determined  by  the  peculiarities  in  each  case  than  on 
more  general  grounds.  Most  Surgeons,  I  think,  would  however  prefer 
ligaturing  the  arteiy  above  the  clavicle,  as  being  a  simpler  proceeding 
than  t^dng  it  below  that  bone ;  which,  moreover,  has  the  disadvantage  of 
bringing  the  scalpel  into  veiy  close  proximit}^  with  the  sac,  which,  were 
it  to  stretch  upwards  under  the  pectoralis  minor  to  a  greater  extent  than 
could  be  discernible  externalhq  might  possibly  be  opened  by  the  knife, 
as  has  even  happened  in  operating  above  the  clavicle.  It  has  been 


AXILLAKY  AND  BRACHIAL  ARTERIES. 


281 


recommended  to  apply  the  ligature  between  the  sac  and  the  origins  ot 
the  subscapiilar  and  posterior  circumflex  arteries,  below  the  former  and 
above  the  latter  ;  but  this  is  an  anatomical  impossibility,  if  the  aneurism 
be  situated  above  the  lower  border  of  the  axilla. 

Compression  of  the  artery  on  the  distal  side  of  the  tumor  succeeded 
in  curino;  the  disease  in  a  case  that  was  under  Goldsmith  of  Yermont. 

The  hemorrhage  from  Wounds  of  the  Brachial  Artery  may  sometimes 
be  arrested  by  the  employment  of  methodical  compression,  but  usually 
it  requires  the  ordinary  ligature  on  each  side  of  the  aperture. 

This  vessel  may  occasionally  be  punctured  in  venesection.  This  acci¬ 
dent,  which  was  formerly  of  frequent  occurrence  when  venesection  was 
practised  by  professed  phlebotomists,  now  very  rarely  happens.  Should 
a  Surgeon  be  so  unfortunate  as  to  puncture  the  brachial  artery  in  this 
way,  he  may  prevent  injurious  consequences  by  keeping  up  a  proper 
degree  of  pressure,  by  means  of  a  graduated  compress  applied  imme¬ 
diately  on  the  occurrence  of  the  accident.  With  this  view,  the  fingers, 
hand,  and  forearm  having  been  very  carefully  padded  and  bandaged,  a 
well-made  graduated  compress  should  be  firmly  applied  over  the  seat  of 
puncture,  and  retained  there  for  at  least  ten  days  or  a  fortnight.  Should 
the  aperture  in  the  artery  not  be  closed  in  this  way,  either  a  circum¬ 
scribed  false  aneurism,  a  varicose  aneurism,  or  an  aneurismal  varix,  will 
form  accordins:  to  its  situation  in  relation  to  the  vein. 

In  the  Circumscribed  Traumatic  Aneurism  at  the  bend  of  the  arm, 
following  a  wound  of  the  brachial  artery,  we  have  the  usual  soft  or 
semi-solid  pulsating  tumor,  which  can  readily  be  emptied  on  pressure, 
and  possesses  more  or  less  bruit.  This  disease  may  be  treated  in  one  of 
three  ways:  1,  by  compression  upon  or  above  the  tumor;  2,  by  ligatur¬ 
ing  the  artery  leading  to  it;  or  3,  by  cutting  through  the  sac,  and 
deligating  the  vessel  on  each  side  of  the  aperture  in  it. 

The  compression  of  the  tumor  has  often  been  successfully  practised. 
It  may  be  done  by  means  of  a  graduated  compress  on  the  tumor,  and 
the  application  of  a  ring-tourniquet  over  the  artery:  the  tumor  becoming 
consolidated,  and  gradually  undergoing  absorption.  In  emplo3dng 
compression  great  care  must  be  taken,  however,  not  to  induce  sloughing 
of  the  tissues  over  the  tumor  by  sudden  and  too  forcible  pressure.  The 
limb  should  be  carefully-  bandaged  up  and  maintained  in  the  semi-flexed 
position.  Should  this  plan  not  succeed,  we  must  be  guided  in  our 
ulterior  measures  by  the  particular  conditions  of  the  case.  If  the  tumor 
be  of  recent  origin,  soft  and  compressible;  or  though  of  longer  duration, 
large,  with  a  thin  sac,  and  danger  of  becoming  diffused,  it  should  be 
treated  by  direct  incision,  and  the  arteiy  be  deligated  on  each  side  of 
the  wound  in  it.  Should,  however,  the  tumor  be  small,  or  but  of  mode¬ 
rate  size,  and  the  sac  be  tolerably  thick  and  firm,  so  as  to  admit  of  the 
deposit  of  laminated  fibrine,  we  may  treat  it  by  deligation  of  the  brachial 
artery,  either  in  the  middle  of  the  arm,  or,  as  Anel  did  with  success, 
immediately  above  the  tumor.  In  the  event,  however,  of  the  disease 
not  being  cured  in  this  waj^,  incision  of  the  sac  must  be  had  recourse  to, 
as  I  have  known  to  be  necessary  in  a  case  in  which  the  brachial  artery 
was  tied  above  the  tumor,  which  was  large,  with  a  thin  sac,  the  pulsu- 
tions  returning  in  a  few  days,  and  the  tumor  continuing  to  enlarge. 

Varicose  Ameurism^  at  the  bend  of  the  arm,  presents  the  ordinary 
character  of  the  disease.  Occasionally,  though  rarely',  it  would  appear 
that  the  aperture  of  communication  between  the  aneurismal  sac  and  the 
vein  becomes  closed,  and  thus  the  varicose  is  converted  into  the  ordinary 
circumscribed  traumatic  aneurism. 


282 


WOUNDS  OF  SPECIAL  BLOODVESSELS. 


The  Treatment  of  this  affection  must  be  conducted  on  different  prin¬ 
ciples  from  that  of  the  ordinary  circumscribed  variety ;  for  whatever  be 
the  density  of  the  sac,  it  is  never,  as  has  already  been  explained  (p.  274), 
a  perfect  one,  having  always  an  opening  into  tlie  vein  wdiich  would  pre¬ 
vent  its  proper  closure  by  the  deposit  of  laminated  fibrine.  In  four 
cases  related  by  Sabatier,  which  were  treated  by  Ariel’s  operation,  ampu¬ 
tation  became  necessary  in  two  ;  and,  in  the  other  cases,  the  operating 
by  incision  of  the  sac  was  required  before  a  cure  could  be  effected.  The 
sac  must  therefore  be  laid  open,  and  the  vessel  tied  on  each  side  of  it  in 
the  way  that  has  been  recommended  in  the  treatment  of  varicose  aneu¬ 
rism,  and  with  the  caution  there  laid  down.  If  the  varicose  aneurism  be 
converted,  after  a  few  days,  into  the  circumscribed  form,  the  aperture 
into  the  vein  becoming  occluded,  ligature  of  the  artery  above  the  sac 
may  be  successfully  employed,  or  compression  may  succeed  in  curing 
the  disease. 

In  Anurismal  Varix  of  the  arm,  a  roller  and  compress  are  all  that 
can  be  required. 

Vessels  of  the  Forearm  and  Palm. — The  arteries  of  the  forearm 
are  very  commonly  wounded  by  pieces  of  glass,  earthenware,  or  knife- 
cuts.  In  every  case  the  bleeding  point  must  be  cut  down  upon,  and  both 
ends  of  the  vessel  tied.  This  rule  is  peculiarly  imperative  in  this  situation, 
on  account  of  the  freedom  of  the  anastomosis  through  the  palmar  arches. 
In  many  of  these  cases  the  bleeding  is  at  first  very  free,  but,  being 
arrested  by  pressure,  does  not  break  out  again  until  eight  or  ten  days 
have  elapsed  ;  when,  the  arm  being  much  infiltrated  with  blood,  inflamed, 
and  swollen,  double  ligature  of  the  vessel  at  the  seat  of  injury  has  to  be 
practised  under  somewhat  difficult  and  unfavorable  circumstances. 

Traumatic  Aneurism  of  the  Radial  and  Ulnar  Arteries  usually 
assumes  the  circumscribed  form,  owing  to  the  pressure  employed  at  the 
time  of  injury  confining  the  extravasation.  If  it  be  small  and  recent, 
and  situated  superficially  at  the  lower  part  of  the  forearm,  or  if  it  be  in 
any  way  diffused,  the  better  plan  is  to  cut  down  upon  and  through  the 
tumor  at  once,  ligaturing  the  vessel  on  each  side.  If,  however,  the 
aneurism  be  deeply  seated  amongst  the  mass  of  muscles  at  the  upper 
part  of  the  forearm,  near  the  elbow-joint,  the  wound  having  healed,  and 
the  soft  parts  covering  it  being  healthy  and  firm,  the  advice  given  by 
Liston  appears  to  be  most  judicious:  rather  than  cutting  through  the 
muscles,  and  detaching  their  connections,  he  recommends  that  the  aneu¬ 
rism  should  be  left  to  attain  some  consistence,  and  then  that  the  brachial 
artery  be  secured  in  the  mid-arm.  In  such  cases  as  these,  also,  compres¬ 
sion  of  the  brachial,  with  moderate  pressure  on  the  tumor  itself,  has 
effected  a  cure. 

Wounds  of  the  Palmar  Arches  not  unfrequently  occur  from  the  break¬ 
ing  of  glass  or  china  in  the  hand,  or  stabs  from  some  pointed  instrument, 
and  are  always  troublesome  to  manage.  If  the  Surgeon  see  the  case 
shortly  after  the  infliction  of  the  wound,  he  may  endeavor,  by  enlarging 
the  aperture  to  a  moderate  extent,  and  with  due  attention  to  the  tendons 
and  nerves  of  the  part,  to  secure  the  bleeding  vessel.  Should  he  fail  in 
doing  this,  which  he  certainl3^  will  if  it  be  the  deep  arch  that  is  injured, 
a  graduated  compress  must  be  well  and  firmly  applied.  If  this  be  pro- 
perlj’^  done,  it  will  very  commqnl}’^  be  an  effective  means  of  arresting  the 
hemorrhage.  If  it  be  loosely  and  ineffectually  put  on,  it  will  be  worse 
than  useless.  The  proper  mode  of  putting  on  this  compress  is  as  follows. 
A  tourniquet  having  been  applied  on  the  brachial  arterj’’,  the  wound  must 
be  carefully  cleared  of  all  foreign  bodies,  wiped  dry,  and  lightly  touched 


ARTERIES  OF  THE  LOWER  LIMB. 


283 


with  the  nitrate  of  silver;  each  finger  is  then  to  be  separately  and  care¬ 
fully  bandaged.  A  wooden  splint  is  then  to  be  put  on  the  back  of  the 
hand  and  the  lower  part  of  the  forearm.  A  firm  well-made  graduated 
compress  is  now  to  be  placed  with  the  apex  downwards  on  the  wound, 
so  as  to  bring  and  press  the  edge  together,  and  securelj’  bandaged  against 
it.  Tlie  circulation  through  the  limb  should  still,  if  possible,  be  con¬ 
trolled  with  a  ring-tourni(iuet,  applied  on  that  artery  above  the  wnfist 
which  appears  most  to  correspond  with  the  arch  wounded,  or,  better  still, 
on  the  lu-achial  itself;  or  the  elbow  may  be  forcibly  flexed,  and  the  fore¬ 
arm  bandaged  to  the  arm  in  this  position,  so  that  tlie  hand  rests  upon 
the  shoulder.  The  compress  and  limb  must  be  left  undisturbed  for  at 
least  five  or  six  daj^s,  when,  the  brachial  being  compressed,  the  dressings 
ma}’  be  taken  off,  and  the  state  of  the  palm  examined.  Should  the 
wound  l)e  healing  and  look  well,  the  hand-splint  and  compress  maj’  be 
reapplied  ;  but  should  the  palm  be  sloughy  and  infiltrated,  with  a  hemor¬ 
rhagic  tendenc}’,  it  will  be  useless  again  to  resort  to  compression,  and 
other  means  must  be  employed. 

Should  an  ineffectual  attempt  have  been  made  to  arrest  the  primary 
hemorrhage,  or  should  the  case  not  be  seen  until  several  days  have 
elapsed,  when  secondary  hemorrhage  has  occurred,  and  the  palm  has 
become  infiltrated  and  swollen,  pressure  can  no  longer  be  borne  upon 
the  seat  of  injury,  and  it  is  useless  to  endeavor  to  search  for  the  injured 
vessel  in  the  midst  of  sloughy  and  infiltrated  tissues,  through  a  narrow 
wound  which  cannot  be  enlarged  without  danger  of  disorganizing  the 
hand.  In  these  circumstances,  it  is  necessaiy  to  deviate  from  the  ordi¬ 
nary  rule  of  practice  in  wounded  arteries,  and  the  Hunterian  operation 
must  be  performed.  The  Surgeon  may  either  tie  both  arteries  above  the 
wrist,  or  at  once  deligate  the  brachial.  Both  methods  of  treatment  have 
their  advocates.  I  prefer  the  simultaneous  ligature  of  the  two  arteries 
of  the  forearm,  just  above  the  wrist,  where  they  are  superficial  and  very 
easily  reached.  In  several  cases  under  m3’  care,  the  radial  and  ulnar, 
immediatel3’’  above  the  hand,  have  been  tied  at  the  same  time  with  com¬ 
plete  success,  and  I  have  never  seen  a  case  in  which  this  operation  has 
failed;  but  should  it  do  so,  or  should  hemorrhage  occur  after  this,  as 
might  happen  in  the  case  of  an  enlarged  median  or  interosseous  arteiy, 
the  Surgeon  must  have  recourse  to  compression  or  ligature  of  the  brachial. 

Circumscrihed  Traumatic  Aneurism  in  the  Palm  is  b}’  no  means  of 
frequent  occurrence.  It  ma}’,  however,  follow  wounds  of  the  palmar 
arches.  In  such  a  case  as  this,  it  would  be  clearl}^  out  of  the  question 
to  la3’  open  the  sac,  and  to  search  for  the  injured  vessel  in  the  midst  of 
the  aponeurotic  and  tendinous  structures  of  the  hand.  It  would  conse¬ 
quently  be  necessaiy,  either  to  tie  the  radial  and  ulnar  arteries  imme- 
diatel}^  above  the  wrist,  or  to  ligature  the  brachial  in  the  upper  arm. 
The  latter  plan  should  be  preferred ;  as,  were  the  first  mode  of  treat¬ 
ment  put  into  practice,  the  sac  might  continue  to  be  fed  b3"  the  interos¬ 
seous  arteiy,  as  happened  in  a  case  of  Roux’s,  in  which  the  patient  died 
of  hemorrhage  from  the  palmar  aneurism  after  the  ligature  of  both  arte¬ 
ries  of  the  forearm.  In  the  case  represented  (Fig.  113),  Liston  success- 
full3’  ligatured  the  brachial  in  the  mid-arm,  after  compression  upon  it 
had  failed  to  effect  a  cure. 

Vessels  of  the  Lower  Limb. — The  hemorrhage  from  the  Femoral 
Artery  and  its  Branches  when  wounded  is  alwa3’s  veiy  profuse.  In  all 
cases,  ligature  of  the  wounded  vessel  at  the  seat  of  injuiy  should  be 
practised. 

If  a  Diffused  Traumatic  Aneurism  have  already  formed,  the  artery 


284 


WOUNDS  OF  SPECIAL  BLOOD-VESSELS. 


should  be  commanded  by  a  tourniquet,  as  it  passes  over  the  brim  of  the 
pelvis,  the  sac  laid  open,  and  the  bleeding  vessel  sought  for  and  tied. 
Guthrie  has  collected  a  great  number  of  cases,  which  prove  incontestably 
that  the  general  principles  of  treatment  in  wounded  arteries  must  not 
be  departed  from,  when  the  arteries  of  the  groin  or  thigh  are  wounded. 
On  the  contrary,  the  facility  with  which  in  most  cases  the  circulatioii  is 
kept  up,  and  the  readiness  with  which  secondary  hemorrhage  comes  on 
as  a  consequence  of  the  free  anastomoses  in  this  situation,  render  the 
rule  of  practice  of  appl^dng  a  ligature  on  each  side  of  the  wound  in  the 
vessel  peculiarly  stringent  in  all  recent  arterial  wounds  in  this  part  of 
the  body.  Secondary  hemorrhage  and  gangrene  of  the  limb  are  the 
great  sources  of  danger  here.  When  gangrene  is  imminent,  or  has  come 
on,  amputation  is  necessarily  the  sole  resource.  With  regard  to  secon¬ 
dary  hemorrhage  supervening  after  ligature  of  the  artery  at  the  seat  of 
injury^  there  is,  I  think,  no  safe  course  but  removal  of  the  limb.  Where 
the  arteiy  has  been  tied  higher  up,  as,  for  instance,  when  the  external 
iliac  has  been  ligatured  for  recent  wounds  or  traumatic  aneurisms  in  the 
groin  or  upper  part  of  the  thigh,  the  hemorrhage  appears  to  have  re¬ 
turned,  or  gangrene  to  have  supervened  in  all  the  cases.  This  fact  was 
remarkably  illustrated  in  the  Crimean  war.  Thus,  Macleod  states  that 
the  French  in  one  hospital  at  Constantinople  ligatured  the  femoral  at  a 
distance  from  the  wound  for  secondary  hemorrhage  seven  times,  and 
that  all  the  cases  failed. 

If  the  traumatic  aneurism  have  assumed  a  circumscribed  character, 
it  must  be  treated  on  the  principles  laid  down  for  this  form  of  the  dis¬ 
ease,  the  supplying  artery  being  ligatured  above  the  tumor ;  and  cases 
are  not  wanting  in  proof  of  the  success  of  this  practice. 

It  occasionally,  though  rarely,  happens  that  a  Varicose  Aneurism  is 
formed  in  the  groin  or  upper  part  of  the  thigh,  as  the  result  of  wound 
of  the  artery  and  vein  in  this  situation.  It  usually  presents  the  ordi¬ 
nary  characters  of  this  disease,  but  some  peculiarities  have  occasionally 
been  met  with.  Thus,  in  a  case  related  by  Horner,  there  was  a  w’avy 
motion  in  the  femoral  vein  on  the  uninjured  side,  arising  from  the  blood 
in  the  wounded  vessel  communicating  a  thrill  upwards  to  that  contained 
in  the  vena  cava.  In  a  case  related  by  Morrison,  it  is  stated  that  a  tu¬ 
mor,  as  large  as  the  human  uterus  at  the  third  month  of  pregnancy, 
communicated  with  the  injured  vein. 

The  Treatment  of  this  disease  is  exceedingly  unsatisfactory.  Of  four 
cases  in  which  the  external  iliac  artery  was  tied,  a  fatal  termination 
occurred  in  every  instance ;  two  of  the  patients  dying  of  gangrene  of 
the  limb,  and  the  remaining  two  of  secondary  hemorrhage  and  consecu¬ 
tive  pneumonia.  It  has  consequently  been  proposed  by  Guthrie  that  the 
tumor  be  laid  open,  and  the  artery  secured  above  and  below  the  aper¬ 
ture  in  it.  As  this  plan  has  never  been  fairly  put  into  practice,  it  would 
perhaps  be  useless  to  speculate  on  the  chances  of  success  likely  to  attend 
it ;  yet  we  must  bear  in  mind,  that  laying  open  an  aneurism  of  this  kind 
in  the  groin  is  a  veiy  different  matter  from  adopting  the  same  procedure 
at  the  bend  of  the  arm,  or  in  a  situation  where  the  Surgeon  can  readily 
command  the  artery  on  the  proximal  side  of  the  sac.  The  gush  of  blood 
from  so  large  an  arteiy  as  the  common  femoral  would  be  so  great  that, 
with  whatever  rapidity  the  operation  were  performed,  there  would  be 
considerable  risk  of  the  patient  suffering  a  fatal  hemorrhage,  before  the 
vessel,  matted  and  incorporated  as  it  would  be  with  surrounding  parts, 
could  be  separated  and  secured ;  and  the  ligature  of  the  vessel  would 
probably  be  followed  by  gangrene  of  the  limb.  The  danger  of  a  fatal 


GLUTEAL  ARTERY. 


285 


result  from  immoderate  hemorrhage  has  now  been  completely  obviated 
by  the  use  of  the  aorta-compressor. 

Recent  wounds  and  traumatic  aneurisms  of  a  diffused  kind,  connected 
with  the  Arteries  of  the  Leg  and  Foot,  require  to  be  treated  by  the  free 
exposure  of  the  bleeding  orifice  in  the  vessel,  and  its  inclusion  between 
two  ligatures.  In  doing  this,  if  the  wound  be  situated  in  the  posterior 
tibial  or  peroneal  artery,  the  Surgeon  will  have  to  cut  freel}^  by  the  side 
of  or  throuo-h  the  muscles  of  the  calf.  This  he  must  do  in  the  direction 
of  their  fibres,  injuring  them  by  transverse  incision  as  little  as  possible; 
and,  by  taking  the  track  of  the  wound  as  his  guide,  the  bleeding  vessel 
will  at  last  be  reached,  and  must  then  be  tied  in  the  usual  way.  Such 
an  operation,  practised  on  a  person  with  a  muscular  limb  that  is  infiltra¬ 
ted  with  blood  and  inflammatory  effusions,  is  in  the  highest  degree  difli- 
cult;  and,  deterred  by  these  difficulties.  Surgeons  have  often  attempted 
to  arrest  the  hemorrhage  by  the  ligature  of  the  superficial  femoral  or 
popliteal  arteries.  The  French  more  particularly  adopt  Anel’s  operation 
in  such  cases,  usually  ligaturing  the  popliteal;  and  though  this  practice 
has  occasionally  been  successful,  as  happened  in  a  case  in  which  I  saw 
the  popliteal  ligatured  for  consecutive  hemorrhage  from  a  wound  of  the 
posterior  tibial  artery,  by  my  respected  master,  Samuel  Cooper,  and  in 
another  instance  in  which  Dupuytren  successfully  ligatured  the  femoral 
for  a  diffused  traumatic  aneurism  of  the  posterior  tibial,  from  wound 
with  a  pistol-ball,  3’et  I  full^^  concur  with  Guthrie  in  deprecating  it  as 
contrar}^  to  good  surgeiy,  and,  with  him,  regard  the  success  that  has 
occasionally’  followed  these  operations  as  purely*  accidental.  In  secon¬ 
dary  hemorrhage  from  the  deep  arteries  of  the  leg,  compression  of  the 
superficial  femoral  should  be  tried,  the  limb  being  at  the  same  time 
bandaged  and  elevated.  Should  these  means  fail  in  arresting  the  bleed¬ 
ing,  no  more  time  must  be  lost,  and  the  Surgeon  should  never  hesitate 
to  amputate  the  patient’s  limb.  In  no  other  way  do  I  believe  that  the 
patient  has  a  fair  prospect  of  safety^ 

Small  Circumscribed  Aneurisms  are  occasionally’  met  with  in  the  foot, 
in  consequence  of  the  wound  of  one  of  the  plantar  arteries,  as  in  opera¬ 
tions  for  club-foot.  If  pressure  have  failed  in  preventing  or  curing  the 
disease,  the  only’  course  left  to  the  Surgeon  is  to  lay  the  tumor  open, 
and  to  ligature  the  artery’  on  each  side  in  the  usual  w’ay. 

Gluteal  Artery. —  Traumatic  Aneurisms  of  the  Gluteal  Artery  are 
of  less  frequent  occurrence  than  might  a  priori  have  been  imagined, 
from  the  situation  of  the  vessel,  exposing  it  to  injury’.  These  aneurisms 
may  acquire  an  enormous  size.  In  John  Bell’s  celebrated  case,  the 
tumor  is  said  to  have  been  of  “prodigious  size,”  and  to  have  contained 
eight  pounds  of  blood.  In  Sy’me’s  case  the  tumor  was  as  large  as  a 
man’s  head  at  the  base,  occupied  the  whole  hip,  and  rose  into  a  blunt 
cone. 

The  Treatment  that  should  be  adopted  in  these  cases  is  to  compress 
the  aorta  by’  means  of  Lister’s  tourniquet;  then  to  lay’  open  the  tumor 
freely*,  turn  out  its  contents,  and  pass  a  ligature  by  means  of  an  aneu¬ 
rism  or  nsevus  needle  round  the  short  trunk  of  the  gluteal  as  it  emerges 
from  the  pelvis. 


286 


ENTRANCE  OF  AIR  INTO  VEINS. 


CHAPTER  XYII. 

ENTRANCE  OF  AIR  INTO  VEINS. 

The  Entrance  of  Air  into  a  Wounded  Vein,  though  an  accident  of 
rare  occurrence,  is  one  that  occasions  such  peculiar  and  alarming  symp¬ 
toms,  that  it  becomes  necessaiy  to  be  acquainted  with  the  circumstances 
attending  it;  and  its  study  is  the  more  interesting  to  the  practical 
Surgeon,  as  it  is  chiefly  in  the  course  of  operations  that  this  condition 
occurs. 

In  surgical  practice,  we  meet  onl}"  with  spontaneous  admission  of  air 
into  the  circulation.  This  was  first  observed  in  the  3’ear  1818,  in  a  case 
in  which  the  internal  jugular  vein  was  opened  during  the  removal  of  a 
large  tumor  from  the  right  shoulder  by  Beauchesne.  The  investigation 
of  this  subject  is  consequently  a  comparatively  recent  matter,  in  w'hich 
the  labors  of  the  Commissioners  of  the  French  Academy  are  conspicu¬ 
ous,  and  the  names  of  Magendie,  Amussat,  Cormack,  and  Wattmann  are 
distinguished. 

Results  of  Experiments  on  Animals. — As  cases  of  the  entry  of 
air  into  the  veins  comparatively  seldom  occur  in  man,  it  is  necessary  to 
study  the  phenomena  accompanying  it  on  the  lower  animals.  It  has 
long  been  known  to  physiologists  that  the  forcible  introduction  of  air 
into  the  circulation  w’ould  kill  an  animal ;  and  Morgagni,  Valsalva, 
Bichat,  and  NA^sten  have  made  this  a  subject  of  observation  and  experi¬ 
ment.  The  death  of  the  animal  in  these  cases  appears  to  be  dependent 
parti}’  on  the  quantity  of  air  injected,  and  partly  on  the  rapid it}^  with 
which  it  is  thrown  in.  Bichat  supposed  that  a  single  bubble  injected 
into  the  circulation  killed  the  animal  with  the  rapidity  of  lightning;  but 
this  is  erroneous,  as  shown  by  Nysten.  I  have  on  several  occasions 
injected  two  or  three  cubic  inches  of  air  into  the  jugular  vein  of  a  dog, 
without  producing  death,  though  much  distress  resulted.  The  rapidity 
with  which  the  air  is  thrown  in  exercises  a  considerable  influence  upon 
the  result.  If  blown  in  quickly,  a  small  quantity  may  kill ;  if  thrown  in 
slowly  and  gradually,  a  large  quantity  ma}’  be  injected  without  destrojdng 
life,  the  blood  appearing  to  dissolve  and  carr}’  away  the  gaseous  fluid. 
In  experiments  which  I  have  made  on  the  subject,  I  have  observed  tlio 
following  iflienomena  in  cases  wdiere  death  w’as  produced. 

On  exposing  the  internal  jugular  vein  low  in  the  neck,  and  puncturing 
it  at  a  place  where  the  flux  and  reflux  of  the  blood  are  plainly  discern¬ 
ible,  there  is  perceived,  in  the  first  inspiratoiy  effort  made  by  the  animal 
after  the  wound,  a  peculiar  lapping  or  gurgling  liquid,  hissing  sound: 
the  nature  of  the  sound  depending  partly  on  the  size  and  the  situation 
of  the  o}jening  in  the  vessel.  At  the  same  time,  a  few  bubbles  of  air  are 
seen  to  be  mixed  with  blood  at  the  orifice  in  the  vein.  The  entrance  of 
the  air  is  immediately  followed  by  a  struggle  during  the  deeper  inspira¬ 
tions,  in  which  fresh  quantities  of  air  gain  admittance,  the  entrance  of 
each  portion  being  attended  by  the  peculiar  sound  above  described.  On 
listening  now  to  the  action  of  the  heart,  a  loud  churning  noise  will  be 
heard,  s3'nchronous  with  the  ventricular  S3’stole ;  and  the  hand  will,  if 
applied  to  the  parietes  of  the  chest,  perceive  at  the  same  time  a  peculiar 


SPONTANEOUS  ENTRY  OF  AIR  INTO  VEINS. 


287 


bubbling,  thrilling,  or  rasping  sensation,  occasioned  hy  the  air  and  blood 
being,  as  it  were,  whipped  together  amongst  the  columnse  carnese  and 
chordae  tendineae.  As  the  introduction  of  air  continues,  the  circulation 
becomes  graduall}'  more  feeble  and  languid  ;  the  heart’s  action,  however, 
being  fully  as  forcible  as  natural,  if  not  more  so.  The  animal  soon 
becomes  unable  to  stand  ;  if  placed  upon  its  feet,  it  rolls  over  on  one 
side,  utters  a  few  plaintive  cries,  is  convulsed,  extrudes  the  feces  and 
urine,  and  dies.  If  the  thorax  be  immediately  opened,  it  will  be  seen 
that  the  heart’s  action  is  continuing  regularly  and  forcibl}’,  and  that 
the  pulmonic  cavities,  though  filled,  do  not  appear  distended  beyond 
their  ordinary  size. 

Death  occurs,  as  I  have  shown  in  a  paper  on  this  subject,  published 
in  the  158th  number  of  the  Edinburgh  Medical  and  Surgical  Journal^ 
in  conseipience  of  the  air  and  blood  being  beaten  up  together  in  the  right 
cavities  of  the  heart  into  a  spumous  froth,  which  cannot  be  propelled 
through  the  pulmonary  vessels  ;  hence  there  is  a  deficient  supply  of  blood 
to  the  brain  and  nervous  centres,  and  fatal  syncope  comes  on,  attended 
usuall}’  by  convulsions.  In  addition  to  this  the  frothy  mixture  in  the 
ventricles  becomes  unable  to  close  the  valves  of  the  heart,  and  the  organ 
soon  comes  to  a  stand-still. 

Spontaneous  Entry  of  Air  into  the  Veins  of  Man  is  attended 
b}"  two  distinct  sets  of  phenomena,  one  of  a  local,  the  other  of  a  con¬ 
stitutional  character. 

Local  Phenomena. — These  consist  in  a  particular  sound,  produced  by 
the  entrance  of  the  air,  and  in  the  appearance  of  bubbles  about  the 
wound  in  the  vein.  The  sound  is  of  a  hissing,  sucking,  gurgling,  or 
lapping  character,  and  never  fails  to  indicate  the  dangerous  accident 
that  has  occurred.  When  once  heard,  whether  in  man  or  the  lower 
animals,  it  can  never  be  mistaken.  It  has  fortunatel}"  fallen  to  my  lot 
to  hear  this  sound  in  the  human  subject  on  one  occasion  only — that  of 
a  patient  who  had  attempted  suicide  b}^  cutting  his  throat.  The  internal 
jugular,  being  w'ounded,  was  being  raised  for  the  purpose  of  having  a 
ligature  passed  under  it;  at  this  moment  a  loud  hissing  and  gurgling 
sound  was  heard,  some  bubbles  of  air  appeared  about  the  w’ound,  the 
patient  became  faint,  and  greatly  oppressed  in  his  breathing.  The  liga¬ 
ture  was  immediately  tightened,  the  faintness  gradually  passed  off,  and 
no  bad  consequences  ensued. 

The  ConHtitutional  Effects  are  usuall}^  very  marked.  At  the  moment 
of  the  entry  of  the  air,  the  patient  is  seized  with  extreme  faintness,  and 
a  sudden  oppression  about  the  chest ;  he  usually’  screams  out  or  exclaims 
that  he  is  dead  or  dying,  and  continues  moaning  and  whiniiig;  the  pulse 
becomes  nearl}^  imperceptible,  and  the  heart’s  action  laboring,  rapid,  and 
feeble;  death  comrnonlj"  results,  but  not  instantaneously,  in  man}'  cases 
at  least.  Thus  Beauchesne’s  patient  lived  a  quarter  of  an  hour  after 
the  occurrence  of  the  accident ;  Mirault’s  between  three  and  four  hours ; 
and  Clemont’s  several  hours.  Amongst  the  other  recorded  fatal  cases,  I 
have  not  been  able  to  find  any  but  vague  statements  as  to  the  length  of 
time  during  which  the  patients  survived. 

If  the  patient  survive  the  immediate  effects  of  the  accident,  he  may 
probably  recover  without  any  bad  symptoms^  as  happened  in  the  case  to 
which  I  have  referred  as  occurring  at  the  University  College  Hospital, 
and  in  an  instance  recorded  by  B.  Cooper.  The  presence  of  the  air  in 
the  pulmonic  capillaries  would  appear  in  some  cases  to  act  as  an  irritant, 
and  to  induce  fatal  pneumonia  or  bronchitis,  as  happened  to  the  patients 
of  Roux  and  Malgaigne. 


288 


ENTRANCE  OF  AIR  INTO  VEINS. 


Cause. — The  cause  of  the  spontaneous  entry  of  air  into  the  veins  has 
been  very  completely  investigated  and  determined  by  the  French  Com¬ 
mission.  If  we  open  a  large  vein  at  the  root  of  a  dog’s  neck,  near  the 
thorax,  in  which  the  venous  pulse,  or  flux  and  reflux  of  blood,  is  per¬ 
ceptible,  we  shall  see  that  air  rushes  in  at  each  inspiration — but  onl}^  at 
this  time — never  gaining  entry  during  expiration.  This  is  owing  to  the 
tendency  to  the  formation  of  a  vacuum  within  the  thorax,  more  particu¬ 
larly  in  the  pericardium,  during  inspiration.  This  suction  action,  or 
“  venous  inspiration,”  is  confined  to  the  large  vessels  in  and  near  the 
thoracic  cavity,  being  limited  by  the  collapse  of  the  coats  of  the  veins  at 
a  little  distance  from  this.  If  the  veins  w’ere  rigid  tubes,  it  would  extend 
throughout  the  body;  but  as  they  are  not,  it  ceases  where  the  coats  col¬ 
lapse.  It  is  indeed  limited  to  that  part  of  the  root  of  the  neck  and  the 
axilla  where  the  venous  flux  and  reflux  are  perceptible ;  and  the  space  in 
which  it  occurs  has  been  termed  the  “dangerous  region.”  But  in  cer- 
tain  circumstances,  air  may  spontaneously  gain  admission  at  points 
beyond  this. 

It  is  well  known  that  what  is  called  by  the  French  Surgeons  the 
“canalization”  of  a  vein,  or  its  conversion  into  a  rigid  uncollapsing  tube, 
is  the  condition  which  is  most  favorable  to  the  introduction  of  air  into  it. 
Indeed,  except  in  tliose  situations  in  which  there  is  a  natural  movement 
of  flux  and  reflux  of  the  blood  in  the  veins,  this  accident  cannot  occur 
unless  these  vessels  be  canalized,  or,  in  other  words,  prevented  from 
collapsing.  This  canalization  of  the  vessel  may  be  occasioned  in  a 
variety  of  ways.  Either  the  cut  vein  may  be  surrounded  by  indurated 
areolar  tissue,  which  will  not  allow  it  to  retract  upon  itself,  but  keeps  it 
open  like  the  hepatic  veins  ;  or  the  coats  of  the  vessel  may  have  acquired, 
as  a  consequence  of  inflammation  or  hypertrophy,  such  a  degree  of 
thickness  as  to  prevent  their  falling  together  when  divided.  Then,  again, 
the  principal  veins  at  the  root  of  the  neck  have,  as  Berard  has  pointed 
out,  such  intimate  connections  with  the  neighboring  aponeurotic  struc¬ 
tures,  that  they  are  constantly  kept  in  a  state  of  tension,  so  that  their 
sides  are  held  apart  when  they  are  cut  across.  The  contractions  of  the 
platysma  and  other  muscles  of  the  neck  may  likewise,  as  Sir  C.  Bell  has 
shown,  have  a  similar  effect.  In  removing  a  tumor,  also,  that  is  situated 
about  the  neck,  the  traction  exercised  upon  its  pedicle  may,  if  this  con¬ 
tains  a  vein,  cause  it  to  become  temporarily  canalized  ;  and  the  incomplete 
section  of  the  vessel,  especially  in  a  transverse  direction,  must  prevent 
the  approximation  of  the  sides  of  the  incision  in  it,  which  will  be  rendered 
open  and  gaping  by  the  retraction  of  the  surrounding  tissues.  This 
patentcy  in  the  incision  in  the  vein  is  apt  to  be  increased  by  the  position 
that  is  necessarily  given  to  the  head  and  arm,  in  all  operations  of  any 
magnitude  about  the  shoulders  and  neck.  Lastly,  the  introduction  of 
air  into  a  vein  will  be  favored  by  the  vessel  being  divided  in  the  angle 
of  a  wound,  the  vein  being,  when  the  flaps  that  form  that  angle  are 
lifted  up,  rendered  open-mouthed  and  gaping. 

On  looking  over  the  reports  of  cases  in  which  air  gained  admittance 
into  the  veins  during  operations,  it  will  be  found  that  these  vessels  were 
alwa3^s  in  one  or  other  of  the  above-mentioned  conditions.  Thus,  in 
Beauchesne’s  case,  air  was  introduced  in  consequence  of  incomplete 
division  of  the  external  jugular,  immediately  above  the  right  subclavian, 
whilst  in  a  state  of  tension,  during  the  removal  of  a  portion  of  the  clavicle. 
In  a  case  that  occurred  to  Dupuytren,  a  large  vein  connected  with  a  tumor, 
and  communicating  with  the  jugular,  was  cut  at  the  last  stroke  of  the 
scalpel,  whilst  the  tumor  was  being  forcibly  drawn  up.  The  vein  was 


PREVENTIVE  TREATMENT. 


289 


found  to  be  adherent  to  the  sides  of  a  sulcus,  so  that  it  remained  gaping 
when  cut.  In  a  case  related  by  Delpech,  there  was  h3’pertrophy  of  the 
axillary  vein,  causing  it  to  gape  like  an  artery.  In  Castara’s  case  there 
was  incomplete  section  of  a  vein,  which  opened  into  the  subscapular 
whilst  the  tumor  was  being  raised  up.  In  Roux’s  case  a  vein  in  the 
neck  was  opened,  whilst  a  tumor,  which  was  being  removed  from  that 
region,  was  being  forcibly  raised  in  order  to  dissect  under  it.  Ulrick 
saw  the  accident  occur  in  consequence  of  the  incomplete  division  of  the 
internal  jugular  vein,  which  was  implicated  in  a  tumor  in  the  neck.  A 
similar  case  happened  to  Mirault  of  Angers,  the  internal  jugular  being 
divided  to  half  its  extent.  A  case  occurred  to  Warren,  in  which  the  air 
entered  b}--  the  subscapular  vein,  the  coats  of  which  were  healthy,  but  in 
a  state  of  tension  in  consequence  of  the  position  of  the  arm  ;  and  another, 
in  which  the  same  accident  happened  from  the  division  of  a  small  trans¬ 
verse  branch  of  communication  between  the  external  and  internal  jugular, 
whilst  in  a  state  of  tension.  Mott,  whilst  removing  a  tumor  of  the  parotid 
gland,  opened  the  facial  vein,  which  was  in  a  state  of  tension  in  conse¬ 
quence  of  the  position  of  the  patient’s  head,  when  air  was  introduced. 
A  case  is  related  by  Malgaigne  in  which  this  accident  happened  in 
consequence  of  the  incomplete  section  of  the  external  jugular  vein,  which 
was  enveloped  in  a  tumor  that  was  being  removed.  Begin  also  relates 
a  case  in  which  air  entered  in  consequence  of  the  puncture  of  the  internal 
jugular  vein  whilst  he  was  removing  a  tumor  from  the  neck. 

These  cases,  which  are  all  that  I  have  been  able  to  meet  with  in  which 
the  condition  of  the  wounded  vein  w’as  particularized,  show"  clearly  what 
is  the  state  of  the  vessel  and  of  the  surrounding  parts  that  is  most 
likely  to  favor  the  occurrence  of  the  accident,  and  consequently  what 
the  Surgeon  should  particular!}’’  guard  against  in  the  removal  of  tumors 
about  the  neck  and  shoulders  ;  viz.,  incomplete  division  of  the  veins,  and 
the  employment  of  forcible  traction  on  the  diseased  mass  at  the  moment 
of  using  the  scalpel.  In  removing  tumors  from  the  neck  and  shoulder, 
it  is  in  many  cases  impossible  to  avoid  drawing  them  forcibly  upwards 
or  forwards,  in  order  to  get  at  their  deeper  attachments ;  but  if  this  be 
necessary  the  chest  should,  for  reasons  that  will  immediately  be  pointed 
out,  be  tightly  compressed,  so  that  no  deep  inspirations  may  be  made  at 
the  moment  that  the  knife  is  being  used,  or  before  a  divided  or  wounded 
vein  can  be  effectually  secured. 

Preventive  Treatment. — When  a  patient  is  under  the  knife,  the  respira¬ 
tions  are  generally  shallow  and  restrained,  the  breath  being  held,  whilst 
eveiy  now  and  then  there  is  a  deep  gasping  inspiration ;  at  which 
moment,  if  a  vein  be  opened  in  wdiich  the  pulse  is  perceptible,  or  which 
is  canalized,  air  must  necessarily  be  sucked  in  ;  and,  as  has  already  been 
said,  in  quantity  and  force  proportioned  to  the  depth  of  the  inspiration. 
This,  then,  being  the  case,  the  mode  of  guarding  against  the  introduction 
of  air  into  the  veins  is  obvious.  The  chest  and  abdomen  should  be  so 
tightly  bandaged  with  broad  flannel  rollers  or  laced  napkins,  as  to 
prevent  the  deep  gasping  inspirations,  and  to  keep  the  breathing  as 
shallow  as  possible,  consistently  with  the  comfort  of  the  patient.  I 
have  often  found  that  the  entrance  of  air  into  the  veins  of  a  dog  could 
be  arrested  by  forcibly  compressing  the  chest  of  the  animal,  so  as  to 
confine  the  respiratory  movements ;  but  that,  as  soon  as  a  deep  inspira¬ 
tory  effort  was  made,  the  compression  having  been  removed,  a  rush  of 
air  took  place  into  the  vessel.  If,  therefore,  during  an  operation  about 
the  root  of  the  neck  or  summit  of  the  thorax,  the  chest  be  bandaged,  as 
here  recommended,  the  Surgeon  must  be  careful  not  to  remove  the  com- 
VOL.  I. — 19 


290 


ENTRANCE  OF  AIR  INTO  VEINS. 


pression  until  the  operation  is  completed,  and  the  wound  dressed;  for  if 
this  precaution  be  not  attended  to,  the  patient  will  most  probably,  on 
the  bandage  being  loosened,  make  a  deep  inspiration,  and  the  air  may 
be  sucked  in  at  the  very  moment  when  all  appears  safe. 

Curative  Treatment. — Different  plans  have  been  recommended  by  Sur¬ 
geons  for  the  treatment  of  those  cases  in  which  air  has  already  gained 
admittance  into  a  vein  ;  but,  from  the  very  fatal  nature  of  this  accident, 
it  does  not  appear  that  much  benefit  has  resulted  from  any  of  them  ;  the 
recoveiy  of  the  patient,  in  some  of  the  cases,  appearing  to  be  rather  due 
to  the  quantit}^  of  air  that  was  introduced  being  insufficient  to  cause 
death,  than  to  any  effort  on  the  part  of  the  Surgeon.  The  two  principal 
modes  of  treatment  that  have  been  recommended,  consist  in  the  suction 
o  f  the  air  from  the  right  auricle.,  and  the  employment  of  compression  of 
the  chest.  Thus  Jkinussat  and  Blandin  advise  us  to  introduce  the  pipe 
of  a  syringe,  a  female  catheter,  or  a  flexible  tube,  into  the  wounded  vein, 
if  it  be  large  enough  to  admit  the  instrument;  and  if  not,  to  open  the 
right  jugular,  and  pass  it  down  into  the  auricle,  and  then  to  employ 
suction,  so  as  to  empty  the  heart  of  the  mixture  of  blood  and  air.  At 
the  same  time  that  this  is  being  done,  we  are,  say  they,  to  compress  the 
chest  as  forcibly  as  possible,  so  as  to  squeeze  more  of  the  air  out  of  the 
heart.  Magendie  and  Rochoux  advise  suction  alone ;  and  Gerdy  recom¬ 
mends  us  to  be  content  with  compression  of  the  chest.  Warren  (of 
Boston)  directs  us  to  have  recourse  to  bleeding  in  the  temporal  artery^  to 
tracheotomy.,  or  to  stimulants.,  according  to  the  condition  of  the  patient. 

The  indications  that  present  themselves  in  the  treatment  appear  to  me 
to  be  threefold  : — 

1.  To  keep  up  a  due  supply  of  blood  to  the  brain. 

2.  To  maintain  the  powers  of  the  heart  until  the  obstruction  in  the 
pulmonic  capillaries  can  be  overcome  or  removed. 

3.  To  remove,  if  possible,  the  obstruction  in  the  capillaries  of  the  lungs. 

We  shall  now  see  how  far  the  means  already  mentioned,  viz.,  suction, 

compression,  etc.,  can  fulfil  these  indications. 

Suction  would  no  doubt  be  highly  advantageous  if  we  could,  by  this 
or  any  other  means,  remove  the  air  that  has  gained  access  to  the  heart, 
and  thus  prevent  the  pulmonic  capillaries  from  being  still  further  ob¬ 
structed.  But,  putting  out  of  consideration  the  difficulty  of  finding  the 
wounded  vein  ;  the  still  greater  difficulty  of  introducing  a  suitable  tube 
a  sufficient  distance  into  it ;  the  danger  of  allowing  the  ingress  of  a 
fresh  quantit}^  of  air,  whilst  opening  the  sides  of  the  incision  in  the  vein 
so  as  to  introduce  the  tube ;  and  the  risk  there  would  be,  if  the  patient 
recovered  from  the  effects  of  the  accident,  of  having  phlebitis  induced  ; 
putting  aside  all  these  circumstances,  which  appear  to  me  to  be  most 
serious  objections,  it  becomes  a  question,  according  to  Amussat,  who  is 
one  of  the  strongest  advocates  of  this  mode  of  practice,  whether,  by 
suction,  with  a  syringe,  or  even  by  the  mouth,  any  material  quantity  of 
air  can  be  removed.  He  says  that,  even  when  the  tube  is  introduced 
into  the  right  auricle,  much  more  blood  than  air  is  constantly  withdrawn. 
These  considerations,  then,  should,  I  think,  make  the  Surgeon  hesitate 
before  having  recourse  to  such  a  hazardous  mode  of  procedure. 

The  next  plan,  that  of  circular  compression  of  the  chest,  however 
valuable  it  may  be  in  preventing  the  ingress  of  air,  can,  when  that  fluid 
has  once  been  introduced  into  the  veins,  have  no  effect  in  removing  it 
from  the  circulatory  S3’stem.  We  cannot,  by  any  compression  that  we 
ma}'-  emplo}",  squeeze  the  air  out  of  the  heart.  But  compression  may 
not  onl}^  be  productive  of  no  positive  good,  but  may  even  occasion  much 


CURATIVE  TREATMENT. 


291 


mischief,  by  embarrassing  still  farther  the  already  weakened  respiratory 
movements,  and  thus  interfering  wdth  the  due  aeration  of  the  small 
quantity  of  blood  that  may  yet  be  traversing  the  lungs. 

Bleeding  from  the  temporal  artery  can  by  no  possibility  be  productive 
of  any  but  an  injurious  effect,  by  diminishing  the  already  too  small  quan¬ 
tity  of  blood  in  the  arterial  system.  Opening  the  right  jugular  vein  may, 
perhaps,  to  a  certain  extent,  be  serviceable,  by  unloading  the  right 
cavities  of  the  heart,  as  John  Reid  has  shown  it  to  be  capable  of  doing; 
and  it  has  been  recommended  by  Cormack  on  this  account.  Lastlj’, 
tracheotomy  cannot  be  of  any  particular  service,  as  the  arrest  of  the 
respiratory  function  is  secondaiy,  and  not  primary. 

1.  What,  then,  are  the  measures  that  a  Surgeon  should  adopt  in  order 
to  prevent  the  occurrence  of  a  fatal  termination  in  those  cases  in  which 
air  has  been  accidentally  introduced  into  the  veins  during  an  operation? 
Beyond  a  doubt,  the  first  thing  to  be  done  is  to  prexent  the  further 
ingress  of  air^  by  compressing  the  wounded  vein  with  the  fingers,  and, 
if  practicable,  securing  it  by  a  ligature.  At  all  events,  compression  with 
the  finger  should  never  be  omitted  ;  as  it  has  been  shown  b}^  Xysten, 
Amussat,  Magendie,  and  others,  that  it  is  only  when  the  air  that  is 
introduced  exceeds  a  certain  quantity,  that  death  ensues.  All  further 
entry  of  air  having  been  thus  prevented,  our  next  object  should  be  to 
keep  up  a  good  supply  of  blood  to  the  brain  and  nervous  centres^  and 
thus  maintain  the  integrity  of  their  actions.  The  most  efficient  means 
of  accomplishing  this  would  probably  be  the  plan  recommended  by 
Mercier;  who,  believing  that  death  ensues  in  these  cases,  as  in  prolonged 
syncope,  from  a  deficient  supply  of  blood  to  the  brain,  recommends  us 
to  employ  compression  of  the  aorta  and  axillary  arteries,  so  as  to  divert 
the  whole  of  the  blood  that  ma}^  be  circulating  in  the  arterial  system  to 
the  encephalon.  This  appears  to  me  to  be  a  very  valuable  piece  of 
advice,  and  to  be  the  most  effectual  w^ay  of  carrying  out  the  indication. 
The  patient  should,  at  the  same  time  that  the  compression  is  being 
exercised  on  his  axillary  arteries  and  aorta,  or,  if  it  be  preferred,  as  more 
convenient  and  easier  than  the  last,  on  his  femorals,  be  placed  in,  a, 
recumbent  position  as  in  ordinary  fainting,  so  as  to  facilitate  the  afflux, 
of  blood  to  the  head.  The  compression  of  the  axillary  and  femoral 
arteries  may  readily  be  made  bj^  the  fingers  of  two  of  the  assistants  who- 
are  present  at  every  operation  of  importance. 

2.  For  the  fulfilment  of  the  second  indication,  that  of  maintaining- 
the  action  of  the  heart  until  the  obstruction  in  the  capillaries  of  the  lungs 
can  be  overcome  or  removed,  artificial  respiration  should  be  resorted  to 
as  the  most  effectual  means  of  keeping  up  the  action  of  that  organ.  For 
the  purpose  of  keeping  up  artificial  respiration,  Silvester’s  method  is  the 
best,  or  the  Humane  Society’s  bellows  maybe  used  ;  or  the  Surgeon  may 
inflate  with  his  mouth.  Before  inflating  the  lungs,  it  will  be  necessary 
to  remove  everjdhing  that  can  compress  the  chest,  or  interfere  in  any 
way  with  the  free  exercise  of  the  respiratory  movements.  Friction  with 
the  hand  over  the  prsecordial  region,  and  the  stimulus  of  ammonia  to 
the  nostrils,  may  at  the  same  time  be  resorted  to. 

3.  The  third  indication — that  of  overcoming  the  obstruction  in  the 
pulmonic  capillaries — would  probably  be  the  best  fulfilled  by  the  means 
adopted  for  the  accomplishment  of  the  second,  viz.,  artificial  inflation  of 
the  lungs.  That  the  action  of  respiration,  if  kept  up  sufficiently  long,, 
will  enable  the  capillaries  of  the  lungs  to  get  rid  of  the  air  contained  in 
them,  appears  to  be  the  case;  for  1  have  experimentally  observed  that,, 
if  a  certain  quantity  of  air  be  spontaneously  introduced  into  the  jugular 


292  INJURIES  OF  NERVES,  MUSCLES,  AND  TENDONS. 


vein  of  a  dog,  and  artificial  respiration  be  then  established,  and  be  main¬ 
tained  for  half  or  three-quarters  of  an  hour,  a  very  small  quantit}" 
indeed,  if  anj",  will  be  found,  on  killing  the  animal,  in  the  cavities  of  the 
heart,  or  in  the  branches  of  the  pulmonary  vessels.  I  am  aware  that 
this  is  not  altogether  conclusive  of  the  fact,  as  the  air  might  be  dissolved 
in  the  blood,  or  might  still  exist  in  the  capillaries  of  the  lungs,  although 
none  might  be  found  in  the  larger  branches  of  the  pulmonaiy  arteiy ; 
but  still  it  seems  to  me  that  we  can  hardl}’  account  for  the  large  quantity 
of  air  that  will  disappear  when  artificial  respiration  is  kept  up,  in  an}-- 
other  way  than  that  some,  if  not  all  of  it,  passes  out  of  the  capillary 
vessels  into  the  air-cells  of  the  lungs. 


CHAPTER  XYIII. 

SPECIAL  INJURIES  OF  NERVES,  MUSCLES,  AND  TENDONS. 

INJURIES  OF  NERVES. 

Contusion. — Nerves  are  often  contused;  the  injury  producing  a 
tingling  sensation  at  their  extremities,  and  pain  at  the  part  struck. 
These  effects  usuall}^  pass  off  in  the  course  of  a  few’  minutes  or  hours; 
but,  in  certain  conditions  of  the  system,  more  especially  in  the  hysterical 
temperament,  thej^  ma^’’  last  for  a  considerable  period,  and  even  give 
rise  to  neuralgia  of  a  veiy  permanent  character.  In  other  cases  the 
continuance  of  the  symptoms  appears  to  be  less  owing  to  constitutional 
than  to  local  causes;  apparentl3Aieing  due  to  thickening  of  the  neuri¬ 
lemma,  causing  compression  of  the  nerve,  and  thus  producing  a  species 
of  neuralgic  23aral3’sis  of  the  ^Darts  supjfiied  b^’  it,  which  may  become  a 
source  of  nervous  irritation,  leading  eventually  to  disease  of  the  brain  or 
spinal  cord. 

Puncture. — If  a  nerve  be  j^unctured,  unjdeasant  consequences  some¬ 
times  result,  more  esiDeciallj"  in  delicate  women.  Not  01113’'  does  it 
happen  in  such  subjects,  that  the  jiart  below  the  jiuncture  becomes  the 
seat  of  various  tingling,  shooting,  and  burning  jiains,  but  the  neuralgic 
condition  appears  to  travel  iqiwards  along  the  jiroximal  part  of  the 
nervous  trunk.  Thus,  I  have  more  than  once  seen  a  iiuncture  of  one 
of  the  digital  branches  of  the  ulnar  nerve  produce  a  kind  of  iiainful 
liaral3"sis  of  its  trunk,  rendering  the  arm  nearl3*  useless.  I  have  seen 
the  same  effects  occur  in  the  median  nerve,  from  so  slight  a  cause  as  the 
liuncture  of  the  finger  by  a  needle.  It  occasional^  ha^ipens  in  venesec¬ 
tion  at  the  bend  of  the  arm,  that  a  branch  of  the  internal  cutaneous 
nerve  is  jiricked  with  the  lancet,  and  tliat  very  jiersistent  neuralgia 
occurs  in  consequence. 

Division. — Primary  Effects.  "When  a  nerve  is  com2iletel3"  cut  across, 
immediate  2Daral3"sis  of  sensation  and  motion  occurs  in  all  the  parts 
supplied  b3’  it.  Consequentl3^,  if  the  integrity  of  the  nerve  be  essential 
to  life,  as  of  the  iineumogastric,  death  must  ensue.  When  the  nerve  is 
q)artiall3’  divided,  or  bruised  as  well  as  severed,  as  in  case  of  gunshot 
injuiy,  neuralgia  in  the  parts  supiilied  by  it,  and  sometimes  at  the 
proximal  end,  is  associated  with  the  iiaral3’tic  s3un2itoms.  Tbe  patient 
comiilains  of  numbness  or  deadness  in  the  jiart  supjilied  by  it,  and  all 


DIVISION  OF  NERVES. 


293 


tactile  sensibility  is  lost;  but  various  anomalous  painful  sensations  of  a 
burning,  trickling,  tingling,  or  creeping  kind  are  complained  of.  These 
sensations  usually  give  the  idea  of  increased  heat  of  the  part  to  the 
patient,  and  are  compared  by  him  to  the  effect  that  would  be  produced 
by  molten  lead  or  boiling  water  running  through  it.  But  the  sensation 
of  heat  is  deceptive,  for  the  part  will  be  found  on  examination  to  be 
actually  colder  than  natural.  Thus  I  found  in  a  woman  who  was  under 
my  care  for  a  wound  of  the  forearm,  b}^  which  the  ulnar  nerve  had  been 
divided,  that  twenty-one  da3's  after  the  injuiy  the  temperature  between 
the  ring  and  the  little  finger  of  the  injured  side  was  6“  Fahr.  below  that 
of  the  same  spot  in  the  opposite  hand. 

The  Secondary  Effects  of  division  of  a  nerve  consist  in  various  modi¬ 
fications  of  sensibility  not  onl}^  in  the  parts  supplied  by  it,  but  also  in 
some  cases,  as  in  the  instance  of  puncture,  in  the  proximal  part  of  the 
trunk  of  the  injured  nerve  above  the  seat  of  its  division.  These  effects, 
consisting  of  neuralgic  pains  and  sensations  of  all  kinds,  and  of  vaiying 
degrees  of  intensit}^,  from  creeping  and  tingling  up  to  real  tic,  are  always 
associated  with  more  or  less  paralj^sis,  and  are  doubtless  due  in  a  great 
measure  to  the  compression  of  the  injured  part  of  the  nerve  by  inflam¬ 
matory  infiltrations,  and  the  condensation  of  its  sheath  b}’^  plastic 
deposits.  Besides  these  effects,  the  nutrition  of  the  part  supplied  by 
the  injured  nerve  becomes  seriously  modified.  The  part  becomes  con¬ 
gested,  bluish,  oedematous,  and  colder  than  natural.  The  skin  peels,  and 
becomes  rough,  or  the  seat  of  vesicular  or  bulbous  eruptions,  which  are 
apt  to  degenerate  into  sluggish  and  unhealth}^  ulcers.  The  muscles  be¬ 
come  flabby  and  wasted;  and  ultimately  deformit}^  of  various  kinds  ma}^ 
ensue  from  the  disturbance  of  the  proper  balance  of  antagonism  between 
the  different  sets  of  muscles  of  the  part. 

As  union  gradually  takes  place  between  the  opposite  ends  of  the 
divided  nerve,  the  various  phenomena  that  have  just  been  described 
gradually  subside,  and  complete  restoration  of  the  normal  sensibilit}", 
mobilit}",  and  nutrition  of  the  part  eventuall^^  takes  place.  In  some  im¬ 
portant  cases,  however,  this  does  not  happen,  and,  the  nerve  about  the 
seat  of  its  division  becoming  implicated  in  a  mass  of  dense  cicatricial 
tissues,  a  traumatic  neuroma  is  developed,  which,  just  as  in  similar 
conditions  in  stumps,  maj-  become  the  seat  and  the  source  of  the  most 
intense  sufierings — the  neuralgic  pains  darting  like  electrical  shocks 
downwards  to  the  terminal  branches,  and  upwards  along  the  trunk  and 
the  secondaiy  divisions  of  the  affected  nerve. 

Repair. — If  a  cut  nerve  be  examined  shortly  after  the  injury,  it  will 
be  found  to  have  become  slightly  bulbous  at  the  extremity,  nervous 
matter  having  escaped  from  the  neurilemma,  and  fibrine  being  thrown 
out  around  and  between  the  two  ends.  Restoration  of  the  continuit}"  of 
the  nerve  evidently  takes  place,  as  is  shown  b}’’  the  fact,  that  in  the 
course  of  a  few  months  its  functions  graduall}^  become  re-established  in 
its  lower  part,  the  paralysis  slowly  disappearing.  If,  however,  a  portion 
of  the  nerve  have  been  actually  excised,  there  is  no  restoration  of  func¬ 
tion,  as  was  shown  long  ago  by  Haighton.  Schwann  and  Hasse  have 
found  the  return  of  sensibilit}^  and  motion  in  the  Jower  part  of  the  nerve 
to  be  owing  to  nerve-tubes  forming  in  the  uniting  medium,  and  thus 
serving  to  establish  the  continuity  of  the  nerve. 

In  the  Treatment  of  a  cut  nerve,  little  can  be  done  except  to  lessen 
the  sufferings  of  the  patient;  if  a  sensation  of  heat  be  complained  of,  bj^ 
the  application  of  cold;  if  the  part  be  too  cold,  by  stimulating  embroca¬ 
tions  and  frictions.  The  neuralgia  resulting  from  the  implication  and 


294  INJURIES  OF  NERVES,  MUSCLES,  AND  TENDONS. 


compression  of  a  nerve  by  condensed  cicatricial  tissue  has  been  relieved 
b}^  Warren,  who  has  dissected  the  nerve  out  of  the  midst  of  this,  with¬ 
out  dividing  or  otherwise  injuring  it. 

INJURIES  OF  MUSCLES  AND  TENDONS. 

Sprains  or  Strains  of  muscular  parts  without  rupture  of  fibre,  are 
of  veiy  common  occurrence,  especiall}’’  about  the  shoulders,  hip,  and 
loins,  and  are  accompanied  by  much  pain,  stiffness,  and  inability  to 
move  the  part.  When  thej’’  occur  in  rheumatic  subjects,  these  injuries 
not  uncommonly  give  rise  to  severe  and  persistent  S3"mptoms ;  in  some 
cases  painful  atrophy,  rigidity,  or  local  paral3"sis  of  the  injured  muscle 
being  induced. 

In  the  Treatment  of  these  accidents,  when  recent,  it  will  be  found 
that  kneading  or  rubbing  the  part  with  a  stimulating  embrocation,  the 
application  of  diy  cupping,  or,  if  the  pain  be  severe,  the  abstraction  of 
a  few  ounces  of  blood  by  cupping,  together  with  rest,  is  most  efficient. 
If  the  injmy  occur  in  a  rheumatic  constitution,  it  will  be  found  useful  to 
give  colchicum  and  Dover’s  powder  in  the  following  form:  R  Extracti 
Colchici  Acetici,  gr.  j ;  Pulv.  Ipecacuanha  comp.,  gr.  x;  Extracti  Colo- 
C3mthidis  comp.,  gr.  iv;  fiant  pil.  iij.  If  the  pain  continue,  the  applica¬ 
tion  of  the  ‘^thermic  hammer”  is  exceedingl3^  serviceable;  and  if  local 
paral3^sis  or  atrophy  ensue,  the  use  of  the  electro-magnetic  apparatus 
will  be  beneficial. 

Rupture  and  Division. — Subcutaneous  rupture  of  muscles  and 
tendons  not  unfrequentl3^  occurs,  not  so  much  from  aiy^  external  violence 
as  from  the  contraction  of  the  muscle  rupturing  its  owm  substance.  The 
rupture  ma3^  occur  at  one  of  four  points;  in  the  muscular  substance 
itself;  at  the  line  of  junction  between  the  muscle  and  tendon;  through 
the  tendon  ;  and,  lastl3^,  at  the  point  of  insertion  of  the  muscle  or  tendon 
into  bone.  Sedillot  found  that,  in  21  cases,  the  rupture  occurred  at  the 
point  of  origin  of  the  tendon  from  the  muscle  13  times;  and  in  the 
remaining  8,  the  muscle  itself  was  torn.  It  occasionall3^  happens  that 
the  muscular  sheath  is  ruptured,  so  that  the  bell3’'  of  the  muscle  forms  a 
kind  of  hernial  protrusion  through  the  aperture ;  or  the  tendon  may  be 
displaced  by  rupture  of  its  sheath.  This  usuall3^  happens  with  the  long 
head  of  the  biceps,  or  the  extensor  tendons  of  the  fingers. 

These  ruptures  most  commonly  occur  in  middle-aged  people,  who  have 
lost  the  elasticit3"  of  3’outh,  though  their  ph3’sical  strength  is  unimpaired. 
At  the  moment  of  the  rupture  taking  place,  the  patient  usually  experi¬ 
ences  a  sudden  shock,  as  if  he  had  received  a  blow,  and  sometimes  hears 
a  snap.  He  becomes  unable  to  use  the  injured  limb,  and  at  the'part 
where  the  rupture  has  occurred  finds  a  hollow  or  pit,  produced  b3"  the 
retraction  of  the  end  of  the  torn  muscle,  wdiich  is  contracted  into  a  hard 
.lump  above  this. 

These  accidents,  though  troublesome,  are  seldom  serious.  The  tendo 
Achillis,  the  quadriceps  extensor  of  the  thigh,  the  triceps  of  the  arm,  the 
biceps,  the  deltoid,  the  rectus  abdominis,  are  the  tendons  and  muscles 
that  most  commonl3^  give  wa3",  with  the  relative  frequenc3^  of  the  order 
in  which  they  are  placed. 

Muscles  and  tendons  ma3^  be  cut  across  accidentally  or  purposel3’'  in 
almost  any  part  of  the  bod3".  In  these  injuries  there  is  alwa3^s  a  con¬ 
siderable  amount  of  gaping  in  the  wound,  owing  to  the  retraction  of 
])oth  ends,  if  a  muscle  be  divided,  and  of  the  upper  end  onl3',  if  a  muscle 
be  separated  from  its  tendon  or  the  tendon  cut  across. 


RUPTURE  AND  DIVISION  OF  MUSCLES. 


295 


Union, — The  mode  of  union  of  these  injuries  has  been  well  described 
by  Paget.  When  a  tendon  is  cut  or  torn  across,  an  ill-defined  mass  of 
nucleated  blastema  of  a  grayish-pink  tint  is  effused  into  the  areolar  tissue 
and  sheath,  between  the  cut  ends.  About  the  fourth  or  fifth  day  this  has 
become  more  defined,  forming  a  distinct  cord-like  uniting  mass  between 
the  ends  of  the  tendon  ;  in  the  course  of  two  or  three  more  days,  this 
mass  has  become  tough  and  filamantous;  the  tissue  gradually  perfects 
itself,  until  it  closely  resembles  tendinous  structure,  though  for  some 
time  it  remains  dull  white  and  more  cicatricial  in  appearance.  The 
strength  of  this  bond  of  union  is  marvellously  great ;  Paget  found  that 
the  tendo  Achillis  of  a  rabbit,  six  daj^s  after  its  division,  required  a 
weight  of  20  lbs.  to  rupture  it.  In  ten  days  the  breaking  weight  was 
56  lbs.  Divided  muscles  unite  in  the  same  way  as  tendons,  but  less 
quickly,  and  by  a  fibrous  bond. 

Treatment. — The  principle  of  treatment  in  these  cases  is  extremely 
simple;  it  consists  in  relaxing  the  muscles  by  position,  so  as  to  approxi¬ 
mate  the  divided  ends  ;  and  in  maintaining  the  limb  in  this  position  for 
a  sufficient  length  of  time  for  proper  union  to  take  place.  If  muscular 
relaxation  be  not  attended  to,  the  uniting  bond  will  be  elongated  and 
weak,  and  perhaps  altogetlier  inefficient.  Stiffness  and  weakness  are 
often  left  for  a  length  of  time — for  many  months,  indeed — after  union 
has  taken  place  ;  very  commonly,  owing  the  consolidation  of  the  divided 
tendon  to  its  sheath,  and  of  that  to  the  neighboring  soft  structures. 
Warm  sea-water  douches,  followed  by  methodical  friction,  will  greatly 
tend  to  restore  the  suppleness  of  the  parts. 

When  the  tendo  Achillis  is  ruptured,  the  best  mode  of  treatment  con¬ 
sists  in  the  application  of  an  apparatus  formed  of  a  dog-collar  placed 
around  the  thigh  above  the  knee,  from  which  a  cord  is  attached  to  a  loop 
in  the  back  of  a  slipper;  by  shortening  this  cord,  the  leg  is  bent  on  the 
thigh,  and  the  foot  extended,  so  that  the  muscles  of  the  calf  become 
completely  relaxed.  After  this  simple  apparatus  has  been  used  for  two 
or  three  weeks  the  patient  may  be  allowed  to  go  about,  wearing  a  high- 
heeled  shoe  for  some  weeks  longer. 

When  partial  rupture  of  one  of  the  extensor  muscles  of  the  thigh 
takes  place,  the  patient’s  limb  must  be  kept  for  some  little  time  in  the 
same  position  as  for  fractured  patella  ;  and  then  he  may  be  allowed  to 
walk  about  with  a  leather  splint  behind  the  knee,  so  as  to  prevent  flexion 
of  this  joint. 

In  ruptures  of  the  muscles  or  tendons  of  the  arm,  a  sling  is  all  the 
apparatus  required  ;  but  when  these  injuries  occur  to  the  deltoid,  atony 
and  atrophy  are  especially  apt  to  result. 

In  division  of  the  extensor  tendons  of  the  fingers — a  very  common 
accident — the  hand  must  be  kept  extended  in  a  straight  splint  for  some 
weeks,  until  perfect  union  has  taken  place. 


296 


INJUKIES  OF  BONES  AND  JOINTS. 


CHAPTER  XIX. 

INJUKIES  OF  BONES  AND  JOINTS. 

INJURIES  OF  BONES. 

A  BONE  may  be  bruised,  bent,  or  fractured. 

Bruising  of  the  Bone  and  Periosteum  often  occurs,  and  is  usually 
of  no  great  moment.  A  moderate  contusion,  however,  of  a  bone  that 
is  but  thinly  covered,  as  the  shin  or  elbow,  may  give  rise  to  troublesome 
symptoms  from  inflammation  of  the  periosteum.  If  the  contusion  be 
severe,  the  vitality  of  a  layer,  or  even  of  the  whole  substance  of  the 
bone,  maybe  destro^^ed,  as  happens  sometimes  from  the  graze  or  contu¬ 
sion  of  a  bullet;  or  the  bone  may  become  deeply  inflamed,  and  suppu¬ 
ration  take  place  in  its  cancellous  structure.  In  old  people,  the  contusion 
of  a  bone  is  frequently  followed  by  atroph}''  and  shortening,  as  happens 
in  the  neck  of  the  femur ;  in  strumous  constitutions,  it  may  lead  to 
serious  disease  of  the  bone,  ending  in  its  complete  disorganization. 

In  the  Treatment  of  bruised  bone,  leeches  and  fomentations  are  the 
most  important  means  that  we  possess.  The  consequences  will  be  con¬ 
sidered  when  we  come  to  speak  of  necrosis. 

Bending  of  Bone  may  occur  in  two  conditions,  viz. :  without  or 
with  fracture.  Bending  without  fracture  is  most  commonly  met  with  in 
very  young  subjects,  before  the  completion  of  ossification ;  the  bone 
being  healthy,  but  naturally  soft,  at  this  period  of  life.  It  occasionally 
takes  place  in  adult  age,  but  is  then  the  result  of  some  structural 
change,  b}^  which  the  natural  firmness  of  the  osseous  tissue  is  diminished. 
The  bending  most  commonly  occurs  in  the  long  bones,  especially  the 
clavicle,  the  radius,  and  the  femur,  but  sometimes  is  met  with  in  the  flat 
bones,  or  those  of  the  skull,  in  which  depression  takes  place  from  a  blow 
without  fracture  having  occurred.  In  many  cases  of  bending  both  of 
long  and  of  flat  bones,  there  is  partial  fracture  on  the  convex  side — 
the  “  green-stick  fracture”  (see  page  304). 

The  Treatment  is  simple:  the  Surgeon  gradually  straightens  the  bone, 
by  applying  a  splint  on  its  concave  side,  towards  which  the  bone  is 
pressed  bj"  a  bandage  and  a  pad  applied  upon  its  greatest  convexity. 

Fractures  will  be  described  in  the  following  two  chapters. 

INJURIES  OF  JOINTS. 

Contusions. — Joints  are  often  contused  by  kicks,  falls,  or  blows,  so 
as  to  be  severely  injured,  with  much  pain,  and  consecutive  inflammation 
of  the  capsule,  synovial  membrane,  or  other  structures  entering  into  their 
formation.  The  Treatment  should  be  actively  anti-inflammatory,  with 
complete  rest  of  the  art.  In  a  later  stage,  an  elastic  bandage,  cold 
douches,  and  friction,  are  useful. 

In  some  cases  the  bursa,  situated  in  the  neighborhood  of  a  joint,  is 
seriously  bruised,  and  becomes  inflamed;  in  consequence,  there  are  often 
troublesome  suppuration  and  some  sloughing.  IVhen  this  takes  place. 


INJURIES  OF  JOINTS. 


297 


free  incision  into  the  inflamed  part,  in  addition  to  the  ordinary  anti¬ 
phlogistic  treatment,  will  afford  speed}*  and  eftectual  relief  to  the  patient. 

Sprains. — When  a  joint  is  twisted  violently  so  that  its  ligaments  are 
either  much  stretched  or  partially  torn,  though  there  be  no  displacement 
of  the  osseous  surfaces,  it  is  said  to  be  sprained.  These  injuries  are 
exceedingly  painful  and  troublesome  in  their  consequences.  They  most 
frequently  occur  to  the  wrists  and  ankle-joints.  The  pain  is  very  severe, 
and  often  sickening;  and  the  sprain  is  rapidly  followed  by  swelling  and 
inflammation  of  the  joint  and  investing  tissues,  often  very  chronic  and 
tedious.  As  the  inflammation  subsides,  stiffness  and  pain  in  using  the 
part  continue  for  a  considerable  length  of  time,  and  are  in  some  cases 
followed  by  a  kind  of  rigidity  and  wasting  of  the  limb.  In  individuals 
of  a  rheumatic  or  gouty  habit  of  body,  the  inflammation  of  the  joint 
consequent  on  the  strain  is  often  most  tedious  and  chronic,  and  will  only 
yield  to  appropriate  constitutional  treatment;  and  occasionally,  in  stru¬ 
mous  subjects,  destructive  disease  of  the  joint  is  induced. 

Treatment. — If  the  sprain  be  slight,  rubbing  the  part  Trith  a  stimu¬ 
lating  embrocation,  and  giving  it  the  support  of  a  bandage,  are  all  that 
need  be  done.  But  if  it  be  at  all  severe,  more  active  measures  must  be 
had  recourse  to.  These  must  vary  according  to  the  condition  of  the  joint 
when  the  Surgeon  sees  the  patient;  but  they  are  all  conducted  on  the 
principles  of  securing  perfect  rest,  and  subduing  inflammatory  action. 
If  the  Surgeon  see  the  patient  immediately  on  the  occurrence  of  the  acci¬ 
dent,  or  before  swelling  to  any  great  extent  has  occurred,  the  best  plan 
is  to  strap  up  the  joint  very  firmly  with  long  strips  of  plaster,  over  which 
a  starched  bandage  may  be  applied.  This  method  of  treatment,  which 
comprises  rest,  perfect  immobility,  and  compression  of  the  joint,  puts  it 
into  the  best  possible  condition  for  the  repair  of  the  injured  articular 
structures,  and  for  the  prevention  of  consecutive  inflammation.  Should 
inflammation  with  much  swelling  have  set  in,  this  must  be  subdued  by 
keeping  the  joint  for  several  hours  in  cold  water,  or  well  moistened  with 
an  evaporating  lotion,  or  wet  by  means  of  irrigation.  Should  this  not 
check  the  inflammation,  leeches  may  be  freely  applied;  and,  when  the 
swelling  has  somewhat  subsided,  the  joint  should  be  supported  with  an 
elastic  roller  and  plasters,  a  starched  bandage,  or  leather  splints.  In  the 
more  advanced  stages,  when  pain  and  stiffness  alone  are  left,  it  should 
be  well  douched  with  cold  water  twice  a  day,  and  afterwards  rubbed  or 
kneaded  with  soap-liniment,  until  its  usual  strength  and  mobility  are 
restored.  This,  however,  very  commonly  does  not  occur  in  sprains  of 
the  knee  and  ankle  for  many  w'eeks;  a  degree  of  stiffness,  combined  with 
inflammation,  being  left  until  the  stretched  and  lacerated  ligaments  have 
regained  their  normal  condition. 

Wounds  of  Joints. — A  joint  is  known  to  be  wounded  when  synovia 
escapes  from  the  aperture,  or  when  the  interior  of  the  articulation  is  ex¬ 
posed.  If  there  be  any  doubt  as  to  the  wound  having  penetrated  the 
synovial  membrane,  no  attempt  should  be  made  to  ascertain  this  by 
probing  or  otherwise,  as  in  this  way  the  very  occurrence  that  is  to  be 
dreaded  may  be  induced  by  the  Surgeon.  The  question  of  the  wound 
having  penetrated  into  the  interior  of  the  joint  will  speedily  be  cleared 
up  by  the  symptoms  that  supervene. 

Symptoms  and  Effects. — The  severity  of  the  wound  of  a  joint  depends 
not  only  on  the  size  of  the  articulation,  but  on  the  nature  of  the  wound 
and  the  age  of  the  patient. 

When  a  small  joint,  as  that  of  one  of  the  fingers,  is  opened,  the  injury 
may  often  be  recovered  from,  without  destruction  of  the  articuhaion. 


298 


INJUEIES  OF  BONES  AND  JOINTS. 


When  a  large  joint  is  opened,  even  a  small  incised  or  punctured 
wound,  there  is  great  danger  lest  such  extensive  local  mischief  and  con¬ 
stitutional  disturbance  ensue  as  to  lead  to  the  destruction  of  the  articu¬ 
lation,  with  danger  to  the  patient’s  life.  When  the  wound  is  large, 
lacerated,  or  contused,  with  fracture  of  the  articular  ends  of  the  bones, 
one  or  other  of  these  consequences  will  certainly  result.  It  is  especially 
in  adults  that  these  unfavorable  results  ensue  :  in  children,  extensive 
injuries  of  large  joints  may  heal  favorably  ;  though,  if  tlie  child  be  of  a 
strumous  habit,  destructive  action  is  apt  to  be  set  up. 

Traumatic  Arthritis. — The  source  of  danger  in  a  wounded  joint  is  the 
inflammation  set  up  in  the  articulation.  A  few  hours  after  the  infliction 
of  the  injury  the  joint  swells,  becomes  liot  and  painful,  and  throbs.  If, 
under  proper  treatment,  resolution  be  effected,  these  inflammatory  s^^mp- 
toms  will  graduall}'-  subside,  leaving  the  articulation  weak,  tender,  and 
stiff  for  some  considerable  time.  Should,  however,  the  inflammation 
continue,  the  pain  increases,  becoming  tensive  and  excessively  severe. 
If  the  aperture  be  large,  s3movia  freely  escapes,  which  soon  becomes 
mixed  with  inflammatory  products.  If  it  be  small,  little  more  than  a 
puncture,  the  joint  swells,  and  Alls  with  purulent  fluid,  which  will  either 
escape  through  the  original  wound,  or  And  an  outlet  for  itself  through  a 
new  opening.  There  are  startings  in  the  limb,  with  excessive  pain  in 
any  attempt  at  moving  it.  The  constitutional  disturbance  becomes  veiy 
severe,  the  patient  being  occasionally^  carried  off  by  the  violence  of  the 
irritative  fever.  In  other  cases  symptoms  of  purulent  absorption  come 
on,  and  death  results  from  pyaemia. 

If  the  patient  survive  this  period  of  acute  action,  abscesses  will  form 
around  and  above  the  articulation ;  and  the  discharge  from  these,  as  well 
as  from  the  joint,  induces  irritative  fever  and  hectic.  Should  this  danger 
be  passed  through,  and  the  patient  eventually  survive,  it  will  be  with  a 
j^artially  ankyiosed  limb,  the  utility  of  which  is  greatly  impaired. 

The  severity  of  the  symptoms  in  the  wound  of  a  large  joint  is  evidently 
dependent  on  the  extent  and  depth  of  the  synovial  membrane  which 
suppurates,  wounds  of  gingly^moid  being  hence  more  dangerous  than 
those  of  orbicular  joints;  and  on  the  pus  thus  formed  being  pent  up  in 
the  midst  of  tense  and  unyielding  tissues,  from  which  it  has  not  a  free 
exit.  It  is  the  admission  of  air  into  the  joint  that  occasions  the  suppu¬ 
ration  ;  for  we  And  that,  in  the  most  extensive  subcutaneous  wounds  and 
lacerations  of  joints,  such  as  occur  in  dislocations  and  simple  fractures  in 
which  the  capsule  is  widely  torn,  the  ligaments  ruptured,  the  incrusting 
cartilages  and  synovial  membrane  broken  through,  and  the  interior  of  the 
joint  filled  with  blood,  suppuration  never  takes  place,  but  the  lacerated 
joint-structures  heal  kindly^  and  well  in  a  few  weeks,  leaving  the  articu¬ 
lation  almost  unimpaired  in  its  movements.  The  presence  of  air  appears 
also  to  exercise  an  injurious  influence  upon  the  pus  collected  in  the 
depths  of  the  joint,  causing  it  to  become  putrescent  and  acrid,  and  thus 
greatly  increasing  the  local  irritation.  It  is  this  retention  of  acrid 
and  putrescent  pus,  in  contact  with  a  large  inflamed  surface,  that  gives 
rise  to  ataxic  fever  and  pyaemia,  which  so  frequently  prove  fatal  in  these 
injuries.  Of  all  wounds  of  joints,  gunshot  injuries  are  necessarily  the 
worst.  In  these  the  aperture  cannot  possibly  be  closed  and  united  by^ 
the  first  intention ;  it  and  the  track  of  the  ball  must  suppurate.  The 
bones  are  also  usually  splintered,  and  foreign  bodies  of  various  kinds 
are  introduced  into  the  articulation;  hence  the  most  extensive  disor¬ 
ganizing  and  fatal  mischief  commonly  ensues. 

Traumatic  arthritis  differs  from  the  destructive  and  disorganizing 


TREATMENT  OF  TRAUMATIC  ARTHRITIS. 


299 


idiopathic  inflammations  of  joints  in  this:  that,  when  the  inflammation 
occurs  as  the  result  of  a  wound,  the  S3uiovial  membrane  is  the  part 
primarily  affected ;  if  the  cartilages  become  involved,  they  are  so 
secondarily ;  the  articular  ends  of  the  bones  not  participating  in  the 
morbid  action.  When  a  joint  is  the  seat  of  disorganizing  inflammation 
of  an  idiopathic  character,  the  mischief  usually  commences  in  the  osseous 
articular  ends,  or  in  the  cartilage,  the  synovial  membrane  being  often 
the  last  affected.  In  the  traumatic  form,  the  disease  may  be  said  to 
radiate  from  the  centre  of  the  joint;  in  the  idiopathic,  to  proceed  from 
the  circumference. 

In  recent  cases  of  traumatic  arthritis  -we  find  the  synovial  membrane 
swollen,  infiltrated,  gelatinous  in  appearance,  and  of  a  crimson  color ; 
the  contiguous  or  subjacent  portions  of  cartilage  are  softened  and  par¬ 
tially^  eroded.  Under  the  microscope,  a  disruption  of  the  cartilage-cells 
may''  be  observed,  and  the  intervening  substance  is  granular ;  these 
changes  gradually^  cease  in  deeper  sections  of  the  cartilage,  which  wuil 
be  found  to  present  a  healthy  appearance.  In  the  more  advanced  stages 
of  the  disease,  when  the  joint  has  been  suppurating  perhaps  for  months, 
it  will  be  found  that  the  synovial  membrane  is  deeply^  vascular  in  places, 
in  other  parts  pulpy  and  infiltrated  with,  or  replaced  by^,  grayush  or 
yellowish  plastic  matter.  The  cartilages  are  eroded  in  patches  exposing 
the  rough  and  injected  surfaces  of  the  articular  extremity  of  the  bone ; 
where  not  eroded,  they  are  pulpy  and  disorganized.  Occasionally^  partial 
but  unsuccessful  attempts  at  bony^  union  will  have  been  set  up  bet^veen 
the  opposite  exposed  osseous  surfaces. 

In  the  Treatment  of  wounded  joints,  the  first  point  to  be  determined 
must  be  whether  amputation  or  resection  should  be  performed,  or  an 
attempt  made  to  save  the  injured  joint.  If  the  joint  be  small,  and  the 
disorganization  of  bones  or  soft  parts  not  veiy  great,  there  can  be  no 
doubt  that  we  ought  to  attempt,  and  shall  usually  be  able,  to  save  it. 
But  if  it  be  of  one  of  the  larger  articulations,  the  line  of  practice  must 
be  determined  by  the  extent  of  the  injurv,  and  the  age  and  constitution 
of  the  patient.  Tf  the  wound  be  but  small  and  clean  cut,  no  Surgeon 
would  be  justified  in  having  recourse  to  immediate  amputation,  even 
though  it  be  the  knee  that  is  injured.  But  if  the  joint  have  been  exten¬ 
sively  laid  open,  with  much  contusion  and  laceration,  complicated 
perhaps  with  dislocation,  or  with  fracture  and  splintering  of  the  bones, 
the  case  is  different.  In  these  unfavorable  circumstances,  however,  in 
the  upper  extremity,  and  even  in  the  ankle,  the  limb  may  not  unfrequently 
be  saved.  If  the  bones  be  comminuted,  the  removal  of  splinters  and  re¬ 
section  of  the  articular  ends  may^  advantageously''  be  practised  in  many^ 
cases,  more  particularly  if  the  patient  be  young  and  sound  in  constitution, 
and  the  soft  parts  not  too  extensively''  damaged.  But  if  these  be  largely’ 
lacerated  and  widely''  contused,  and  the  patient  aged  or  broken  in  health, 
amputation  is  imperatively  called  for.  This  is  more  especially  the  case 
when  the  knee  is  injured;  extensive  lacerations  of  this  joint,  more 
particularly  when  complicated  with  dislocation  or  comminution  of  the 
bones,  being  cases  for  early  amputation. 

If  it  be  determined  to  make  an  attempt  at  saving  the  joint,  the  principal 
point  is,  if  possible,  to  close  the  wound  by  the  first  intention,  and  thus 
to  prevent  suppuration.  If  it  be  a  puncture,  or  small  clean-cut  wound, 
this  may  occasionally  be  done  by''  bringing  the  edges  together,  and  placing 
a  piece  of  lint  soaked  in  collodion  upon  it,  or  a  strip  of  plaster  washed 
over  with  resin  varnish.  The  joint  must  then  be  placed  in  a  splint 
'plaster  of  Paris  is  the  best),  so  as  to  be  rendered  absolutely^  immovable, 


300 


INJUKIES  OF  BONES  AND  JOINTS. 


and  should  then  be  surrounded  by  India-rubber  bags  containing  pounded 
ice.  In  fact,  the  three  great  principles  of  treatment  in  the  early  stages  of 
wounds  of  joints  consist  in  the  exclusion  Of  air,  perfect  rest,  and  the  con¬ 
tinuous  application  of  dry  cold.  In  this  way  inflammatory  action  may 
be  prevented,  and  the  union  of  the  wound  may  take  place  under  the 
plaster;  but  in  the  majority  of  cases  the  injury  is  followed  by  so 
abundant  a  secretion  of  synovia,  that  the  dressing  becomes  loosened  by 
the  tension  and  outward  pressure  of  the  accumulated  fluid  which  escapes 
from  under  it.  If  the  preventive  means  of  arresting  inflammation  fail, 
and  the  joint  swell,  becoming  red,  hot,  and  throbbing,  with  much  consti¬ 
tutional  irritation,  means  should  be  taken  to  limit  the  inflammatory 
action.  This  is  best  done  by  the  free  application  of  leeches  over  the 
joint,  hot  fomentations,  and  the  internal  administration  of  calomel  and 
opium  about  four  times  in  the  day.  This  remedy  possesses  a  more 
decidedly  controlling  influence  over  traumatic  arthritis  than  any  other 
with  which  I  am  acquainted. 

When  suppuration  has  come  on,  long  and  free  incisions  should  be 
made  into  the  joint,  so  as  to  procure  an  early  outlet  for  the  pus;  the  part 
must  be  well  poulticed,  and  an  attempt  made  at  procuring  ankylosis  by 
the  granulation  and  cohesion,  through  flbrous  tissue,  of  the  articular 
surfaces.  Puncturing  the  joint  is  worse  than  useless.  By  a  puncture, 
the  pus  cannot  be  evacuated  from  a  deep  and  complicated  joint,  but  air 
is  admitted,  and  the  result  is  decomposition  of  secretions,  with  irritative 
fever  and  pyaemia ;  but,  b}^  making  free  and  early  incisions,  the  dangers 
resulting  from  decomposition  of  the  pus  and  its  absorption  into  the 
system  are  in  a  great  measure  lessened,  and  the  constitutional  irritation 
produced  by  the  tension  of  the  parts  is  at  once  removed.  The  joint 
itself  is  not  put  into  worse  condition  by  being  more  freely  opened ;  for, 
when  once  suppuration  has  been  set  up  in  it,  even  to  a  limited  extent, 
destruction  of  its  tissues  must  ensue ;  and  the  patient  may  recover  with 
a  stiff  joint,  amputation  may  become  imperative,  or  he  may  die  from 
constitutional  irritation.  The  most  favorable  result  that  can  be  antici¬ 
pated,  therefore,  is  a  stiff  joint,  and  this  the  Surgeon ‘should  endeavor 
to  obtain.  If  the  case  proceed  favorably,  the  discharge  will  gradually 
lessen,  and  the  constitutional  disturbance  subside.  The  joint  must  then 
be  placed  in  such  a  position,  that,  when  ankylosis  results,  the  limb  may 
be  most  serviceable  to  the  patient.  If,  however,  as  very  frequently 
happens  when  the  larger  joints  are  wounded,  the  suppuration  within  the 
articulation,  and  the  abscesses  that  form  outside  it,  reduce  the  patient 
to  a  hectic  state,  secondary  amputation  speedily  becomes  inevitable. 

"Wounds  of  Individual  Joints. — To  the  preceding  general  prin¬ 
ciples  I  have  little  to  add  with  respect  to  wounds  of  the  individual 
joints. 

The  Hip  and  Shoulder  are  so  deeply  placed,  and  so  well  protected, 
that  they  can  scarcely  be  wounded  except  as  the  result  of  gunshot 
injury,  the  treatment  of  which  condition  has  already  been  discussed 
(pp.  202,  203). 

Wound  of  the  Knee-joint  is  one  of  the  most  common  and  most  severe 
of  such  injuries.  When  the  result  of  gunshot  violence,  it  imperatively 
demands  immediate  amputation.  When  produced  by  a  puncture  or 
clean  cut,  the  wound  must  be  closed,  and  cold  irrigation  and  leeches 
may  be  employed  assiduously.  Should  suppuration  occur,  the  joint 
must  be  freely  laid  open  by  long  incisions,  and  commonly  amputation 
will  be  required.  The  abscess  will  often  form  deeply  in  the  thigh  rather 
than  in  the  joint  itself;  and  in  a  very  insidious  manner.  The  limb 


CAUSES  OF  FEACTUEE. 


301 


swells  up  to  the  trochanters,  becomes  very  tense,  painful,  hot,  and  oede- 
matous,  with  great  constitutional  disturbance  and  irritative  fever.  But 
the  joint  maj''  be  but  little  swollen,  and  many  days  will  often  elapse 
before  fluctuation  can  be  felt  in  it  or  in  the  thigh.  It  is  this  absence  of 
swelling  in  the  knee  itself  that  may  mislead  an  inexperienced  practi¬ 
tioner.  At  length  the  abscess  may  approach  the  surface  near  the  knee  ; 
and,  on  an  incision  being  made,  an  immense  quantity  of  pus  is  dis¬ 
charged.  The  abscess  forms  as  a  consequence  of  the  escape  of  some  of 
the  irritating  contents  of  the  suppurating  s3movial  membrane,  close 
upon  the  anterior  surface  of  the  femur;  it  creeps  up  and  surrounds  the 
bone  under  the  deep  muscles  of  the  limb,  which  are  separated  from  the 
bone,  and  may  reach  as  high  as  the  trochanters  before  it  is  detected.  It 
is  this  depth  in  the  limb  at  which  the  abscess  is  seated  that  occasions 
the  remarkable  difficulty  in  its  detection,  the  violent  constitutional  dis¬ 
turbances  it  occasions,  and  its  extreme  danger.  I  have  never  seen 
abscess  form  among  the  muscles  of  the  leg*  as  a  consequence  of  injuries 
of  the  knee-joint,  unless  the  tibia  had  been  fractured  as  well  as  the  joint 
opened. 

For  the  penetration  of  the  knee-joint  by  needles,  see  p.  186. 

Wounds  of  the  Elbow  and  Ankle-joints^  when  simple,  as  in  punctures, 
usuall}^  admit  of  closure  and  of  being  healed,  leaving  a  sufficiently*  useful 
and  mobile  articulation.  When  they  are  complicated  with  fracture  of 
the  neighboring  bones,  the  soft  parts  not  being  too  extensively  injured, 
resection  of  the  injured  articulations  is  the  proper  course;  if  there  be 
much  laceration  of  soft  parts  with  comminution  of  the  bones,  amputa¬ 
tion,  especially  in  the  case  of  the  ankle,  will  be  required. 

Wounds  of  the  Wrist-joint  are  peculiarly  dangerous,  on  account  of  the 
extent  and  complexity  of  the  synovial  membrane  that  enters  into  its 
conformation,  should  suppuration  be  set  up.  Some  of  the  carpal  bones 
may^  necrose,  and  thus  amputation  may  be  rendered  imperative  ;  or,  if 
this  be  averted,  a  stiff  and  comparatively  useless  hand  will  be  left. 

Dislocations  will  be  described  in  Chapter  XXII. 


CHAPTER  XX. 

FRACTURES. 

The  management  of  Fractures  constitutes  one  of  the  commonest 
duties  of  the  surgeon,  and  hence  the  consideration  of  all  that  relates  to 
their  nature  and  treatment  is  of  the  utmost  importance. 

Causes. — Fractures  are  almost  invariably  the  result  of  local  causes, 
but  the  liability  to  their  occurrence  is  more  or  less  modified  by  certain 
predisposing  circumstances. 

Local  Causes. — Fractures  may  occur  from  the  application  of  external 
violence,  or  from  muscular  action. 

External  violence  may  be  applied  in  two  way*s:  directly  or  indirectly. 

The  worst  forms  of  fracture  are  occasioned  by  direct  external  violence 
the  blow*  crushing  and  splintering  the  bone,  as  by  the  passage  of  a  heavy^ 
wheel  or  a  gunshot  injuiy.  When  the  bone  is  broken  by  direct  violence, 
the  fracture  is  always  at  the  seat  of  injuiy,  and  is  often  complicated  with 


802 


FRACTURES. 


considerable  mischief  to  the  soft  parts,  the  result  of  the  same  force  that 
breaks  the  bone. 

Indirect  violence  may  break  a  bone  in  two  waj'S.  One  that  is  more 
commonly  talked  of  than  seen  is  by  contrecoup^  in  which,  when  a  blow  is 
inflicted  on  one  part,  the  shock  that  is  communicated  expends  its  violence 
on  the  opposite  point,  where  the  fracture  consequently  occurs.  This  form 
of  injury  is  chiefly  met  with  in  the  head  ;  and,  although  its  occurrence 
has  been  denied,  I  cannot  doubt  it,  as  I  have  seen  unequivocal  instances. 

In  the  next  form  of  indirect  violence  occasioning  fracture,  the  bone  is 
broken  by  being  snapped,  as  it  were,  betw'een  a  resisting  medium  on  one 
side,  and  the  weight  of  the  body  on  the  other.  Thus,  a  person  jumping 
from  a  height  and  alighting  on  his  feet,  may  break  his  legs  by  their 
being  compressed  between  the  weight  of  the  body  above  and  the  ground 
below.  The  long  bones  are  those  which  are  most  frequently  fractured  in 
this  way ;  and  the  fracture  occurs  at  the  greatest  convexity  or  at  their 
weakest  point.  When  a  person  jumps  from  a  carriage  that  is  in  motion, 
although  the  fall  be  not  great,  3"et  its  force  is  considerable,  the  bod}" 
coming  to  the  ground  with  the  same  velocity  as  that  with  which  it  was 
being  carried  onwards  in  the  vehicle.  Hence,  fractures  received  in  this 
Ava\^  are  usuall}"  severe,  and  often  compound  or  comminuted. 

Muscular  action  is  not  an  unfrequent  cause  of  fracture  of  those  bones 
into  which  powerful  muscles  are  inserted.  This  is  especially  the  case 
w’ith  the  patella  and  some  of  the  bony  prominences,  such  as  the  acro¬ 
mion,  which  are  broken  in  the  same  wa}-  that  a  tendon  is  ruptured — by 
the  violent  contraction  of  the  muscles  attached  to  them  tearing  them 
asunder.  It  is  not  often  that  the  long  bones  are  so  fractured  ;  but  the 
humerus  has  been  broken  by  a  person  striking  at  but  not  hitting  another, 
or  b}"  suddenl}"  throwing  out  the  arm  to  seize  something  that  was  falling  ; 
and  the  clavicle  has  been  fractured  b}^  a  rider  giving  his  horse  a  back- 
handed  blow.  In  these  cases,  however,  muscular  action  ma}"  not  have 
been  the  sole  cause,  the  weight  of  the  limb  also  tending  to  fracture  the 
bone.  Those  bones  that  do  not  offer  attachment  to  an}"  powerful  mus¬ 
cles,  as  the  cranial,  for  instance,  cannot  be  fractured  in  this  way. 

Predisposing  Causes. — These  are  numerous  and  varied. 

Some  bones  are  especially  liable  to  be  broken  in  consequence  of  their 
serving  as  points  of  support.  Thus,  when  a  person  falls  upon  the  hand, 
the  shock  is  transmitted  from  the  wrist-joint  through  the  radius,  humerus, 
and  clavicle,  to  the  trunk ;  the  radius  and  clavicle,  being  the  weaker 
bones,  are  then  especially  liable  to  be  fractured.  So  again,  the  situation 
of  a  bone,  irrespectively  of  any  other  circumstance,  may  predispose  it 
to  fracture ;  the  prominent  position  of  the  nasal  bones,  and  the  exposed 
situation  of  the  acromion,  render  these  parts  peculiarly  liable  to  this 
injury.  The  shape  of  some  bones  disposes  them  to  fracture ;  thus,  a 
long  bone  is  necessarily  more  readily  broken  than  a  short  and  thick  one; 
hence  fractures  of  the  tibia  and  femur  from  falls  on  the  feet  are  more 
common  than  of  the  os  calcis.  Certain  parts  of  hone  are  more  com¬ 
monly  fractured  than  others.  Those  points  especially  into  which  power¬ 
ful  muscles  are  inserted,  or  that  are  in  exposed  situations,  and  hence 
liable  to  injury,  or  to  receive  the  weight  of  the  fallen  body,  are  often 
broken.  Hence  the  acromion,  the  olecranon,  and  the  neck  of  the  femur, 
are  commonly  fractured. 

Age  exercises  considerable  influence,  not  only  on  the  general  occur¬ 
rence  of  fracture,  but  on  the  peculiar  liability  of  certain  bones.  Though 
fractures  may  occur  at  all  ages,  even  in  intra-uterine  life  (Chaussier  has 


VARIETIES  OF  FRACTURE. 


803 


dissected  a  fostus  that  had  113  fractures),  yet  bone,  being  elastic  and 
cartilaginous  in  early  age,  is  less  readily  broken  than  when  it  has  become 
brittle  and  earthy,  as  in  advanced  life.  In  children,  fractures  most 
commonly  occur  in  the  shafts  of  the  long  bones;  or  at  the  point  of 
junction  between  the  shaft  and  epiphysis,  where  ossification  has  not  as 
yet  taken  place.  This  separation  of  the  epiphysis  in  children,  the  de¬ 
tachment  as  it  were  of  the  terminal  points  of  ossification,  is  not  unfre- 
quently  met  with,  and  occurs  chiefly  at  the  lower  ends  of  the  humerus 
and  femur,  sometimes  in  the  radius  and  other  long  bones.  As  age 
advances,  the  compact  tissue  of  the  shaft  becomes  denser  and  harder, 
but  the  cancellous  structure  of  the  extremities  more  dilated  and  looser ; 
hence  fracture  of  the  neck  of  the  femur  is  especially  common  in  old 
people.  In  young  persons  also,  the  bone  is  usually  simply  broken  trans¬ 
versely,  but  fractures  taking  place  at  a  more  advanced  period  of  life  are 
generally  oblique,  and  often  comminuted  ;  they  also  more  commonl}^ 
extend  into  joints  than  when  occurring  in  early  age.  From  statistical 
tables  of  fractures  of  the  upper  limb  given  by  Flower,  it  appears  that 
below  five  years  of  age  the  liability  of  the  two  sexes  to  fracture  is  equal. 
After  five  the  males  steadily  increase  in  liability  up  to  middle  life.  After 
forty-five  tbe  number  of  fractures  in  females  exceeds  that  in  males,  in 
consequence  of  the  extreme  frequency  of  fracture  of  the  lower  end  of 
the  radius  in  women  above  middle  life.  In  children,  more  than  one-half 
the  fractures  occurring  in  the  upper  limb  were  of  the  clavicle. 

Fracture  termed  spontaneous  sometimes  happens  without  any  very 
direct  cause,  or  under  the  influence  of  violence  that  would  usually  be 
insufficient  to  occasion  it.  This  may  happen  in  consequence  of  the 
texture  of  the  bone  being  weakened  or  rendered  brittle  by  disease,  such 
as  mollities  or  fragilitas  ossium,  by  the  cancerous  cacliexy,  b}^  syphilis, 
by  cancerous  growths  within  the  substance  of  the  bone,  or  by  the  pres¬ 
sure  of  some  neighboring  tumor  causing  absorption.  In  other  cases, 
again,  it  occurs  without  any  apparent  disease,  local  or  constitutional. 
This  usuall}'-  happens  as  the  result  of  the  brittleness  and  weakening 
induced  by  age.  I  have  known  a  gentleman  little  above  fifty,  apparent¬ 
ly  in  perfect  health,  break  his  thigh  with  a  loud  snap  whilst  turning  in 
bed.  In  these  cases  union  rarely  takes  place,  or  not  without  much 
difficulty. 

Sex  necessarily  influences  the  liability  to  fracture,  men  being  more 
frequently  exposed  to  the  causes  of  this  injury  than  women.  In  women, 
the  bones  that  are  most  commonly  fractured  are  the  clavicle,  the  tibia, 
and  the  neck  of  the  femur;  in  men,  the  shafts  of  the  long  bones,  the 
cranium,  and  the  pelvis. 

From  statistical  accounts  it  would  appear  that  the  right  limbs  are 
more  frequently  broken  than  the  left,  being  more  exposed  to  violence. 
The  supposition  that  the  bones  are  more  brittle  in  winter,  and  hence 
break  more  readily  than  at  other  seasons,  is  altogether  a  mistake;  though 
fractures  may  be  common  at  this  period  of  the  year,  from  falls  being 
more  frequent. 

Varieties. — Fractures  present  important  varieties  as  to  their  Nature 
and  their  Direction.  The  varieties  as  to  nature  depend  upon  the  cause 
of  the  fracture,  its  seat,  and  the  age  of  the  patient. 

Nature. — Fractures  are  divided  into  two  great  classes,  according  as 
they  are  unaccompanied  and  attended  by  an  open  wound  leading  down 
to  the  line  of  breakage  in  the  bone — the  first  being  called  Simple.,  the 
second  Compound.  In  the  first  class  are  included  the  Simple  Fracture., 
where  the  bone  is  merely  broken  across,  split,  or  fissured;  the  Impacted^ 


804 


FRACTURES. 


■u’bere  one  fragment  is  wedged  into  another,  the  compact  tissue  being 
driven  into  the  cancellous  structure;  and  the  Comminuted^  where  the 
bone  is  broken  into  several  fragments. 

AVlien  the  soft  parts  are  torn  through,  so  that  the  fracture  communi¬ 
cates  b}’^  a  wound  with  the  surface  of  the  bodj",  it  is  said  to  be  Compound. 
A  fracture  may  be  rendered  compound  in  two  wa^’s;  either  through 
laceration  of  the  soft  parts  by  the  same  injuiy  that  breaks  the  bone,  as 
when  a  bullet  traverses  a  limb,  and  fractures  the  bone;  or  else  by  the 
protrusion  of  one  of  the  extremities  of  the  broken  fragments  through 
the  integuments.  This  necessarily  most  frequentl}’’  happens  when  the 
fragments  are  sharp  and  pointed,  and  the  coverings  thin,  as  in  fracture 
of  the  tibia,  and  may  be  occasioned  by  muscular  contraction,  or  by  some 
incautious  movement  on  the  part  of  the  patient,  driving  the  fragment 
through  the  skin. 

A  fracture  is  said  to  be  Complicated  when  the  injury  to  the  bone  is 
conjoined  with  other  circumstances  which  are  perhaps  of  more  impor¬ 
tance  than  the  mere  fracture,  the  complication  constituting  often  the 
most  serious  part  of  the  injury,  and  influencing  greatl}’-  the  general 
result  of  the  case.  Thus,  a  fracture  may  be  complicated  with  injury  of 
an  important  internal  organ,  as  of  the  brain,  lungs,  or  bladder;  the  in¬ 
jury  to  the  organ  being  inflicted  by  the  projection  against  it  of  one  of 
the  broken  fragments.  A  fracture  is  not  unfrequently  complicated  with 
the  wound  of  one  of  the  principal  arteries  of  the  part,  as  happens  es¬ 
pecially"  in  the  leg,  where  the  tibial  arteries,  being  in  close  contact  with 
it,  are  often  torn  by  the  broken  bone.  In  other  cases,  again,  the  fracture 
is  associated  with  injuiy  of  a  joint  or  dislocation. 

Besides  these  varieties  of  fracture,  it  occasionally  happens  that  a  bone 
is  only  cracked,  or  partially  broken.  This  especially  occurs  in  the  bend¬ 
ing  of  bone  in  children,  in  which  cases  the  fracture  may  be  Partial  or 
Incomplete.,  merely  extending  across  the  convexity  of  the  curve  made 
by"  the  bone.  This  is  sometimes  called  the  '‘'‘green-stick''^  fracture. 

Direction. — The  direction  assumed  by  fractures  varies  greatly,  and 

depends  materially"  on  the  cause  of  the  injury,  as 
Fig.  117.  well  as  upon  the  bone  that  is  fractured. 

h  The  line  of  fracture  may"  run  through  a  bone  in 

three  dififerent  directions ;  either  transversely 
obliquely.,  or  longitudinally  to  its  axis. 

The  Transverse  Fracture  is  the  simplest,  and  is 
seldom  complicated  with  injuiy  to  the  neighboring 
parts.  It  chiefly  occurs  in  children,  and  very  fre¬ 
quently  between  the  articular  extremity  and  the  shaft 
of  a  bone ;  it  unites  readily,  and  is  attended  by  but 
little  displacement.  It  is  most  commonly  the  result 
of  direct  violence,  but  it  may  arise  from  muscular 
action,  as  in  the  case  of  the  patella,  which  is  usually 
broken  in  this  way^ 

The  Oblique  Fracture  commonly  occurs  from  in¬ 
direct  violence ;  the  breaking  force  being  applied 
to  the  ends,  and  not  across  the  shaft.  It  often 
runs  a  Ions:  wav,  more  than  half  the  distance  of 
the  shaft  of  a  bone,  and  is  more  dangerous  than 
the  transverse,  owing  to  the  obliquity  of  the  frac¬ 
ture  causing  the  ends  of  the  bone  to  be  sharply 
Oblique  and  LoDgitudinai  pointed  (Fig.  117,  o),  and  thus  frequently"  to  punc- 
Fractures.  ture  the  skill,  or  to  fierforate  an  artery".  It  is  more 


SIGNS  OF  FEACTURE. 


305 


tedious  in  its  cure  than  the  transverse,  owing  to  the  extent  of  surface 
over  which  the  process  of  repair  has  to  be  carried  on,  and  the  difficulty 
of  keeping  the  fragments  directly  in  apposition  ;  hence,  also,  there  is  a 
greater  liability  to  shortening  of  the  limb;  it  is  jjrincipally  met  with  in 
the  shafts  of  the  long  bones  of  adults  and  elderly  people. 

The  Longitudinal  Fracture  consists  of  a  splitting  or  fissnring  of  a 
bone  in  the  direction  of  its  axis  (Fig.  117,  6).  Longitudinal  fracture, 
or  splitting  of  bone,  is  not  very  common  in  civil  practice;  but  in  mili¬ 
tary  practice  it  is  frequent,  especially  from  the  action  of  conical  rifle- 
balls.  In  such  cases,  when  the  shaft  is  struck  and  shattered,  the  split¬ 
ting  of  the  bone  may  extend  widely  in  either  direction — sometimes  into 
the  neighboring  joint  (Fig.  70,  p.  189),  although,  as  Stromeyer  has  re¬ 
marked,  it  usually  stops  short  of  this,  terminating  at  the  epiphj^sis. 
When  produced  by  a  blow,  and  sometimes  not  a  very  severe  one,  upon 
the  articular  end  of  a  bone,  this  may  be  split  and  the  joint  thus  opened. 

The  Separation  of  the  Fpiphysis  of  one  of  the  long  bones  from  the 
shaft,  at  the  line  of  junction  between  the  two,  is  an  accident  that  occa¬ 
sionally  occurs  in  children  and  young  people  at  any  period  up  to  that 
of  the  completion  of  the  ossification  between  the  parts.  Hence  it  is  usu¬ 
ally  met  with  under  the  age  of  21  or  22.  This  kind  of  fracture  is  always 
transverse.  It  is  apt  to  simulate  a  dislocation  very  closely;  but  the 
diagnosis  may  be  made  by  finding  that  the  articulation  is  always  intact, 
and  its  movements  usually  free.  Union  by  bone  readily  takes  place. 
Not  only  are  the  epiphyses  of  the  long  bones  liable  to  this  separation 
through  the  line  of  junction,  but  the  same  thing  may  happen  to  various 
processes,  as  the  acromion,  olecranon  etc. ;  and  some  osseous  structures, 
as  the  acetabulum  and  sternum,  are  apt  under  external  violence  to  sepa¬ 
rate  into  their  original  component  parts. 

Signs. — Fracture  may  produce  pain,  and  alteration  of  the  bulk  of  the 
limb.  Pain  in  the  limb  ma3^  be  owing  either  to  the  laceration  of  the  soft 
parts  by  the  broken  fragments,  or  to  the  general  injury  inflicted  upon 
it.  Increase  of  size  is  observed  in  some  cases  of  fracture  ;  the  augmented 
size  being  owing  either  to  the  extravasation  of  blood  into  the  limb,  which 
often  takes  place  to  a  very  considerable  extent,  even  without  the  wound 
of  any  principal  vessel ;  or  to  the  approximation  of  the  attachments  of 
the  muscles  by  the  shortening  of  the  limb.  Diminished  bulk,  or  flatten¬ 
ing,  occurs  in  some  cases,  in  consequence  of  the  weight  of  the  limb  draw¬ 
ing  the  part  down,  and  thus  lessening  natural  rotundity.  Neither  pain 
nor  alteration  of  bulk  can  be  regarded  as  pathognomonic  of  fracture. 

The  more  special  and  peculiar  signs  of  fracture  are  three :  1.  A  Change 
in  the  Shape  of  the  Limb ;  2.  Mobilit}''  in  its  Continuity  ;  and  3.  The 
existence  of  Grating  between  the  Broken  Ends  of  the  Bone. 

I.  The  Change  in  the  Bhajoe  of  the  Limb,  due  to  the  displacement  of 
portions  of  the  broken  bone,  is  perhaps  the  most  important  sign  of  frac¬ 
ture  ;  it  manifests  itself  b}^  a  want  of  correspondence  between  the  osse¬ 
ous  points  on  opposite  sides  of  the  body,  by  an  increase  or  diminution 
of  the  natural  curves  of  the  limb,  by  angularity,  shortening,  or  swelling. 

In  investigating  the  existence  and  extent  of  displacement  in  a  case  of 
fracture,  the  Surgeon  should  always  strip  his  patient,  and  compare  the 
corresponding  points  of  bone  on  the  opposite  sides  of  the  bodvq  and  their 
relative  situation  to  some  fixed  and  easily  distinguishable  neighboring 
prominence  on  the  trunk  or  injured  part  of  the  limb.  From  this  the 
measurements  may  be  taken,  b3^  grasping  the  injured  part  and  the  cor¬ 
responding  portion  of  the  healthy  limb  in  each  hand,  and  running  the 
fingers  liglitl}"  over  the  depressions  and  elevations,  marking  any  differ- 
VOL.  I. — 20 


306 


FRACTURES. 


encethat  exists  ;  or,  if  greater  accuracy  be  required,  measuring  by  means 
of  a  tape.  lu  some  cases  the  measurement  must  not  be  made  between 
the  trunk  and  the  limb  injured,  or  even  from  one  extremity  of  the  limb 
to  the  otlier,  as  shortening  of  the  whole  member  might  depend  on  other 
causes  than  fracture,  such  as  wasting,  disease  of  joints,  or  dislocation ; 
when  this  is  the  case,  the  measurement  must  be  taken  between  different 
points  of  the  bone  injured,  and  compared  with  a  similar  measurement  of 
the  sound  limb. 

The  displacement  of  a  broken  bone  maybe  the  direct  result  of  the  vio¬ 
lence  which  occasions  the  fracture,  the  fragments  being  driven  out  of 
their  position,  as  when  a  portion  of  the  skull  is  beaten  in;  or  it  may 
result  from  the  weight  of  the  limb  dragging  downwards  the  lower  frag¬ 
ment,  as  in  a  case  of  fractured  acromion.  In  some  cases  it  is  either  occa¬ 
sioned  or  greatly  increased  b}’  the  direction  of  the  fracture.  Thus,  in 
several  cases  of  broken  tibia  which  have  been  under  my  care,  the  line  of 
fracture  being  oblique  from  above  downwards,  and  from  before  back¬ 
wards,  I  have  found  the  upper  end  of  the  lower  fragment  project  con¬ 
siderably  forwards,  sliding,  as  it  were,  along  an  inclined  plane  in  the 
upper  fragment;  and  in  one  of  these  cases,  which  1  had  an  opportunity 
of  dissecting  after  amputation,  the  direction  of  the  fracture,  rather  than 
muscular  action,  appeared  to  be  the  cause  of  displacement.  In  trans¬ 
verse  fractures  there  is  alwa3's  but  slight  displacement. 

Muscular  contraction  is,  however,  without  doubt  the  most  active  cause 
of  displacement;  hence  it  has  been  found  that,  in  paral3’zed  limbs  which 
are  fractured,  there  is  but  little  deformity.  The  contraction  of  the 
muscles  of  the  part  approximating  their  point  of  attachment,  owing  to 
the  support  or  resistance  offered  b}'  the  bone  being  removed,  draws  the 
most  movable  fragment  out  of  its  normal  position.  The  other  causes 
that  have  just  been  mentioned,  tend  greatly  to  favor  this  kind  of  dis¬ 
placement  ;  but  in  some  cases,  as  in  fractured  patella,  the  displacement 
is  entirely  muscular,  and  in  all  fractures  of  the  long  bones  it  is  chiefly’- 
due  to  muscular  contraction. 

The  Direction  of  the  Displacement  is  principally  influenced  by"  the 
direction  of  the  fracture,  the  position  of  the  limb,  and  muscular  action; 
it  may  be  angular,  transverse,  longitudinal,  or  rotaiy. 

In  the  angular  displacement  there  is  an  increase  of  the  natural  curva¬ 
ture  of  the  limb,  the  concavity  of  the  angle  being  on  the  side  of  the  most 
powerful  muscles ;  thus,  for  example,  in  fracture  of  the  thigh,  the  angle 
projects  on  the  anterior  and  outer  side  of  the  limb,  because  the  strongest 
muscles,  being  situated  behind  and  to  the  inner  side,  tend,  l)y’  their  con¬ 
traction,  to  approximate  the  fragments  on  that  aspect.  This  displace¬ 
ment  principally"  occurs  in  oblique  and  comminuted  fractures. 

The  transverse  or  lateral  displacement  occurs  when  a  bone  is  broken 
directly"  across,  the  fragments  often  hitching  one  against  another,  and  so 
being,  as  it  were,  entangled  together.  In  this  case  there  is  often  but 
very-  little  deformity. 

In  the  longitudinal  displacement  there  may  be  either  shortening  or 
elongation  of  the  limb.  When  there  is  shortening,  as  most  commonly 
happens  in  oblique  fractures,  it  is  dependent  on  muscular  contraction, 
the  broken  ends  of  bone  being  brought  together  so  as  to  overlap  one 
another,  or riding.”  In  other  cases,  the  shortening  may  be  owing  to 
the  impaction  of  one  fragment  in  the  other.  In  some  cases  tliere  is 
preternatural  separation  of  the  fragments,  the  weight  of  the  limb  tend¬ 
ing  to  drag  the  lower  one  downwards,  or  muscular  contraction  drawing 
the  upper  one  away"  from  it. 


DIAGNOSIS  OF  FRACTURE. 


307 


The  rotary  displacement  is  owing  to  the  contraction  of  particular  sets 
of  muscles  twisting  the  lower  fi-agment  on  its  axis,  as  well  as  producing 
shortening  of  the  limb.  Thus,  the  external  rotators  in  intracapsular 
fractures  of  the  neck  of  the  thigh-bone,  and  the  supinators  in  some 
fractures  of  the  radius,  have  a  tendency  to  twist  or  rotate  the  low^er 
fragment  in  an  outward  direction. 

2.  Tlie  occurrence  of  preternatural  Mobility  in  the  Continuity  of  a 
bone  cannot  exist  without  fracture,  and  separation  of  the  fragments 
from  one  another;  hence,  its  presence  may  alwa^'s  be  looked  upon  as  an 
unequivocal  sign  of  the  bone  being  broken.  But  fracture  ma}’  exist 
without  it;  thus,  it  occasional!}'  happens  that  fracture  takes  place,  and 
owing  to  the  impaction  or  wedging  together  of  the  fragments,  mobility 
is  not  perceived. 

3.  Another  sign  of  much  value  in  practice  is  the  occurrence  of  Crep¬ 

itus^  or  rather  of  the  Grating  together  of  the  Rough  Surfaces  of  the 
Broken  Bone^  wiiich  can  be  felt  as  well  as  heard  on  moving  the  limb. 
This  grating  can  only  occur  w'hen  the  fragments  are  movable  and  in 
contact,  and  is  especially  perceptible  when  the  rough  ends  of  the  broken 
bone  are  directly  rubbed  against  one  another,  and  not  the  smooth  peri¬ 
osteal  surfaces  merely  opposed  or  overlapping.  It  is  not,  how'ever,  an 
invariable  accompaniment  of  fracture;  being  absent  in  some  cases, 
in  wdiich  the  fracture  is  firmly  impacted,  or  w'hen  the  fragments  are 
widely  separated.  It  must  not  be  confounded  wfith  the  crepitation  that 
occurs  in  the  limbs  from  other  causes,  as  from  emphysema,  or  from  the 
efliision  of  serous  fluid  into  the  sheaths  of  the  tendons,  which  gives  rise 
to  a  peculiar  crackling  sensation,  very  different  from  the  rough  grating 
of  a  fracture.  , 

It  will  thus  be  seen  that  each  of  these  three  signs,  taken  individually, 
is  more  or  less  equivocal,  and  that  it  usually  requires  a  combination  of 
at  least  tw'O  of  them  to  determine  whether  fracture  exists.  In  ascertain¬ 
ing  the  existence  of  a  fracture,  the  Surgeon  should  make  the  necessary 
manipulations  W’ith  the  utmost  gentleness,  but  yet  effectually,  so  that 
no  uncertainty  may  be  allowed  to  remain  as  to  the  seat  and  nature  of 
the  injury,  more  especially  when  it  occurs  in  the  vicinity  of  a  joint.  The 
increased  mobility  may  be  ascertained  by  fixing  the  upper  fragment  and 
rotating  the  low'er  portion  of  the  limb ;  the  grating  by  drawing  downi 
the  low'er  fragment,  so  as  to  bring  the  rough  surfaces  into  apposition, 
and  then  grasping  the  limb  at  the  seat  of  fracture  with  one  hand,  and 
rotating  it  gently  with  the  other.  The  displacement  must  be  ascertained 
by  measuring  the  limb  carefully  in  the  w'ay  that  has  been  directed,  and 
by  comparing  the  injured  with  the  sound  side. 

Diagnosis. — The  diagnosis  of  an  ordinary  fracture  is  seldom  attended 
by  any  material  difficulty.  The  coexistence  of  displacement,  of  mo¬ 
bility,  and  of  grating,  wfill  usually  enable  the  Surgeon  at  once  and 
readily  to  pronounce  with  certainty  its  existence,  when  it  is  simple. 
When  it  is  compound.,  there  is  frequently  the  additional  evidence  afforded 
by  the  protrusion  of  the  end  of  one  of  the  fragments;  and  if  it  be  com¬ 
minuted  as  w^ell,  the  loose  splinters  will  be  readily  felt. 

There  are,  however,  two  conditions  that  render  the  detection  of  a 
simple  fracture  occasionally  difficult.  The  first  is,  when  only  one  or  two 
or  several  contiguous  bones  is  broken;  the  other,  the  impaction  of  the 
fragments. 

When  only  one  bone  is  broken  in  a  situation  where  there  are  two  or 
more,  as  in  the  leg,  forearm,  metacarpus  or  metatarsus,  very  close  and 
careful  manipulation  of  the  injured  bone  may  be  required.  The  Surgeon 


808 


FKACTUEES. 


must  run  his  finger  carefully  over  the  most  projecting  ridge,  feel  for 
slight  inequality  or  oedema  at  one  part,  and  perhaps  elicit  the  faintest 
occasional  crepitus  on  fully  and  deeply  moving  the  bone  at  the  seat  of 
suspected  fracture. 

In  the  case  of  impaction  the  diagnosis  is  even  more  difficult.  Here  no 
crepitus,  and  no  preternatural  mobility,  can  be  found;  but  the  Surgeon 
must  be  led  to  his  diagnosis  by  the  recognition  of  the  peculiar  dis¬ 
placement  and  distortion  which  may  be  characteristic  of  the  particular 
fracture,  as,  for  instance,  the  deformity  of  the  wrist  in  impacted  frac¬ 
ture  of  the  lower  end  of  the  radius. 

The  difficulties  of  diagnosis  in  fracture  of  a  single  bone,  or  in  an  im¬ 
pacted  fracture,  are  necessaril}^  most  seriously  increased  if  there  be  much 


extravasation  of  blood  into  the  limb;  or,  when  the  fracture 


is  through 


an  articulated  end,  if  there  should  be  much  etfusion  into  the  neighboring 
joint. 

As  has  already  been  stated,  the  existence  of  a  fracture  when  compound^ 
and  more  particularly  if  comminuted^  is  usually  readily  determined. 
Here,  the  great  mobilit}’,  the  protrusion  of  fragments  or  splinters,  and 
the  ready  crepitus,  will  seldom  allow  the  Surgeon  to  be  at  fault.  Should 
any  doubt  exist,  the  introduction  of  the  finger  into  the  wound  will 
enable  him  to  determine  with  certainty,  not  only  the  existence,  but  the 
condition  and  extent  of  the  fracture.  But  with  all  the  assistance  that 
may  thus  be  afforded,  the  very  existence  of  a  bad  compound  and  com¬ 
minuted  fracture  may  be  unsuspected  for  man}^  daj-s,  even  though  most 
careful  examinations  have  been  made  with  the  view  of  ascertaining  its 
presence.  Of  this  important  fact,  which  may  have  weighty  bearings  in 
medico-legal  investigations,  the  following  case  is  a  good  illustration.  A 
young  man  was  shot  wdth  a  wooden  ramrod  through  the  left  hand  and 
shoulder,  by  the  accidental  explosion  of  his  gun  whilst  he  was  loading 
it.  The  ramrod  struck  the  humerus  three  inches  below  the  shoulder- 
joint,  full  on  its  forepart.  It  was  splintered  against  the  bone,  the 

fragments  passing  on  each  side,  and  mostly  escaping 
through  two  apertures  of  exit  posteriorly ;  some  pass¬ 
ing  to  the  inner  side  between  the  large  vessels  and  the 
bone,  the  others  to  the  outer  side  between  it  and  the 
deltoid.  The  patient  was  brought  to  the  Hospital, 
where  I  saw'  him  a  few  hours  after  the  injury,  and,  en¬ 
larging  the  wounds,  extracted  a  number  of  splinters  of 
the  ramrod  from  around  the  bone.  The  limb  was  care¬ 
fully  examined,  not  only  by  me,  but  b}"  several  other 
Surgeons  present,  to  determine  whether  the  bone  had 
been  fractured,  or  the  joint  injured.  There  was  no 
sign  of  fracture  to  be  detected — no  shortening,  no  mo¬ 
bility,  no  crepitus,  no  inequality  wdien  tlie  fingers  were 
freely  passed  into  the  w’ounds,  no  displacement  at  all. 
As  no  fracture  appeared  to  exist,  the  limb  w’as  laid  on 
a  pillow,  and  irrigation  emplo3'ed.  Eiysipelas  set  in, 
followed  by  extensive  and  deep  suppuration  in  the  limb. 
On  examining  this,  with  the  view  of  giving  a  free  exit 
to  the  discharges,  eight  da\'s  after  the  accident,  dis¬ 
placement  and  crepitus  were  for  the  first  time  found, 
and  it  became  evident  that  the  humerus  had  sustained 
a  comminuted  fracture.  The  patient  died  of  pyaemia; 
and  after  death  the  bone  presented  the  appearance  here  given  (Fig.  118), 
a  long  splinter  having  been  detached  in  a  longitudinal  direction,  a  b, 


Comminuted  Frac¬ 
ture  of  the  Hume¬ 
rus  without  dis¬ 
placement. 


UNION  OF  SIMPLE  FRACTURES. 


809 


and  the  shaft  broken  across  at  c.  Here,  then,  was  not  only  a  compound, 
but  a  comminuted  fracture,  detected  for  the  first  time  a  week  after  the 
infliction  of  the  injury.  It  appeared  probable  that  the  blow  of  the  ram¬ 
rod  had  fractured  the  bone  longitudinall}^,  detaching  the  large  splinter, 
which  had  become  impacted ;  and  that  the  shaft  still  held  together  by  a 
narrow  bridge  of  bone  at  c,  which  being  broken  across  subsequently  in 
moving  the  limb,  now  become  heavy  b3"  infiammatory  infiltration,  led  to 
the  shortening  of  the  limb,  and  the  lateral  displacement  of  the  fragments. 

Union  of  Fractured  Bone. — A  fractured  bone  is  ultimately  united 
by  being  soldered  together  b3"the  deposition  of  new  bone  around,  within, 
and  lastl3’ between  the  broken  fragments.  In  exceptional  cases,  as  in 
fractures  occurring  within  the  capsule  of  a  joint,  and  in  those  of  the 
patella  and  the  olecranon,  union  is  effected  by  fibrous  or  filamentous 
tissue.  In  some  instances  that  will  hereafter  be  considered,  owing  to 
peculiar  local  or  constitutional  circumstances,  new  bone  is  not  formed, 
but  the  uniting  medium  is  fibrous. 

The  new  bone  that  constitutes  the  bond  of  the  union  is  termed  Callus. 
In  man3^  cases  a  larger  quantit}'  of  this  is  temporarily  deposited  than 
is  permanentl3'  left.  This  temporal^  formation  of  bone  goes  b}"  the  name 
of  the  promsional  callus.  It  is  formed  partly  external  to  the  fracture, 
incasing  the  broken  ends,  and  partl3^  in  the  medullaiy  canal,  so  as  to 
include  the  fragments  between  la3"ers  of  new  bone,  and  thus  maintain 
them  in  contact.  That  which  is  permanentl3'  left,  and  which  intervenes 
between  the  broken  ends,  is  called  the  definitive  callus.  The  process  of 
union  varies  somewhat  in  simple  and  in  compound  fractures. 

Union  of  Simple  Fractures. — The  production  of  callus  has  been 
studied  with  much  care  b3’  Haller,  Duhamel,  Bordenave  and  Hunter,  by 
Dupuytren,  Breschet,  and  Yillerme,  and  more  recentl3^  by  Stanle3',  Paget, 
and  Billroth.  From  the-  observations  of  these  pathologists,  it  would 
appear  that  the  union  of  a  broken  bone  takes  place  through  the  medium 
of  plastic  matter,  deposited  b3’’  a  process  of  adhesive  inflammation  set 
up  in  the  injured  bone  itself,  in  its  periosteum,  and  in  the  neighboring 
soft  parts ;  the  h’lnph  thus  formed  graduall3"  undergoing  development 
into  osseous  tissue.  The  whole  process,  indeed,  is  strictl3"  analogous  to 
that  which  takes  place  in  the  ordinaiy  healing  of  a  wound  b3"  adhesion 
and  the  development  of  the  cicatricial  tissue.  The  broken  fragments 
are  at  first  movable,  and  surrounded  b3"  a  considerable  extravasation  of 
blood.  In  the  course  of  ten  or  fourteen  da3's,  this  has  ordinaril3'  under¬ 
gone  absorption  to  a  considerable  extent;  the  periosteum  and  the 
medullaiy  membrane  in  the  vicinity  of  the  fractures,  the  tissue  around 
it,  and  the  broken  bone  itself,  become  very  vascular,  and  pour  out  a 
quantit3’’  of  13'mph  between  and  around  the  fragments,  as  well  as  within 
the  medullar3^  canal,  so  that  the  fractured  ends  are  ensheathed  b3^  a  red¬ 
dish  gelatinous  mass  of  a  fusiform  shape,  thickest  opposite  the  seat  of 
injuiy.  This  graduall3"  becomes  more  and  more  consolidated ;  and,  in 
proportion  as  it  becomes  firmer,  the  mobilit3^  of  the  fragments  lessens, 
and,  the  ends  of  the  bone  becoming  smooth  133"  the  plastic  deposit  being 
adherent  to  and  interposed  between  them,  grating  is  less  di stint.  From 
the  third  to  the  fourth  week  the  13’mph  has  assumed  a  sufficient  degree 
of  firmness  to  keep  the  fragments  in  apposition,  though  the  bone  still 
3delds  readil3"  at  the  seat  of  fracture.  This  13’mph,  which  is  poured  out 
not  0013”  b3'  the  periosteum  and  bone,  but  b3"  all  the  soft  parts  in  the 
neighborhood  of  the  fracture,  graduall3' undergoes  ossification,  the  bony 
matter  being  first  deposited  in  a  granular  manner,  but  in  sufficient  quan¬ 
tity  bj'  the  sixth  or  eighth  week  to  unite  the  fracture  rather  firml3’. 


810 


FRACTURES. 


Fig.  119. 


Section  of  Frac¬ 
tured  Tibia,  four 
weeks  after  ac¬ 
cident. 


The  callus,  which  is  at  first  soft  and  spong}",  and  differs  from  old  hone 
in  its  microscopic  as  well  as  ordinaiy  physical  characters,  gradually 
assimilates  to  old  bone,  both  in  hardness  and  in  structure,  osseous  cor¬ 
puscles  and  vascular  laminated  canals  being  formed  in  it ;  and  it  becomes 
smooth  on  the  surface,  being  invested  by  a  dense  cellulo-fibrous  perios¬ 
teum,  until,  by  the  end  of  six  or  eight  months,  ossification  is  perfect. 

Tlie  last  process  in  the  consolidation  of  the  fracture  is  the 
formation  of  new  bone  between  the  broken  ends.  This 
does  not  take  place  definitel}"  until  a  considerable  period 
after  the  ensheathing  callus  has  been  formed.  Billroth,  of 
Vienna,  who  has  investigated  this  process,  finds  that  cells 
are  developed  in  the  Haversian  canals ;  and  tliat  these 
become  dilated  b}^  the  gradual  absorption  of  their  bony 
walls,  while  the  cells  increase  in  number,  and  the  blood¬ 
vessels  form  loops.  Thus  there  is  a  removal  of  old  tissue, 
and  a  deposit  of  new  plastic  matter;  and  these  processes 
go  on  at  both  the  fractured  ends,  so  that  the  new  deposits 
meet  and  unite,  and  ultimately  become  converted  into 
bone.  In  some  instances,  however,  the  plastic  matter, 
instead  of  being  ossified,  undergoes  transformation  into 
a  fibrous  tissue,  as  in  the  ordinary  cicatrices  of  soft  parts, 
giving  rise  to  false  joints,  of  which  we  shall  speak  here¬ 
after.  B3'  the  time  that  the  intermediate  or  definitive 
callus  is  fullj’’  formed,  that  portion  of  the  ensheathing  or 
provisional  callus  which  is  not  required  for  the  preserva¬ 
tion  of  the  permanent  integrity  of  the  bone,  has  been 
gradually  removed,  or  has  moulded  itself  closelj'  to  the 
shape  and  condition  in  which  it  will  ultimately’  remain,  the  medullary 
canal  having  again  become  free,  and  the  ends  of  the  fracture  rounded  off. 
In  some  cases  the  medullaiy  cavity^  is  not  restored  to  its  former  con¬ 
dition  for  a  considerable  time,  continuing  to  be  partially  occluded  by  a 
thin  septum  of  callus. 

According  to  Paget,  the  plastic  matter  that  is  effused  around  and 
between  the  bones  undergoes  ossification  in  various  wavs.  Those  frac- 
tures  that  unite  quickly  do  so  most  commonly  through  ossification  of 
fibrous  tissue  in  a  rudimental  condition,  which  may  be  either  that  of 
nucleated  cells  or  nucleated  blastema.  A  fine  closely  granular  ossific 
deposit  takes  place  in  the  blastema,  and  gradually  forms  the  laminae  of 
a  delicate  cancellous  tissue,  the  nuclei  becoming  probably’ converted  into 
bone-corpuscles.  In  other  cases  again  the  union  may^  be  accomplished 
by’  the  ossification  of  perfect  fibrous  tissue,  developed  from  the  plastic 
matter  thrown  out  around  the  fracture.  Then  again,  the  new  bone  may 
be  formed  by  the  plastic  exudation  passing  through  a  cartilaginous  stage. 
Pure  fetal  cartilage  has  so  far  only  been  seen  in  the  lower  animals  ;  in 
man  the  cartilage  has  always  been  of  the  fibrous  variety^ 

In  those  fractures  that  are  transverse,  and  that  remain  in  steady  appo¬ 
sition  during  ossification,  and  more  especially’  if  they’  be  but  thinly’ 
covered  by’  soft  parts,  the  union  appears  to  take  place  directly’  and  im¬ 
mediately  between  the  opposed  osseous  surfaces;  there  being  no  appear¬ 
ance  of  those  accessory  deposits  of  bone  that  usually’  go  by  the  name 
of  “  provisional  callus.”  If,  however,  the  fracture  occur  in  the  bone 
that  is  thickly  invested  by  soft  parts,  masses  of  new  bone  will  be  thrown 
out  around  the  fragments,  evidently  the  result  of  deposition  from  the 
surrounding  inflamed  tissues  rather  than  from  the  injured  periosteum  or 
bone.  The  influence  of  the  neighboring  soft  parts  in  determining  the 


UNION  OF  COMPOUND  FEACTURES. 


311 


deposits  of  new  bone  is  well  marked  in  the  tibia.  In  a  fracture  of  this 
bone  we  find  that,  at  the  anterior  and  inner  part,  which  is  thinly  covered, 
union  takes  place  directly  between  the  broken  ends  :  but  at  the  posterior 
and  outer  side,  where  there  is  a  thick  envelopment  of  tissue,  a  large  mass 
of  provisional  callus  will  often  be  found,  filling  up  even  the  interosseous 
space.  That  neighboring  parts  participate  in  the  inflammation  set  up 
around  the  fracture,  and  throw  out  callus,  is  evident  from  what  takes 
place  occasional!}''  when  one  of  the  bones  of  the  forearm  or  leg  is  broken. 
Periostitis  is  then  set  up  in  the  unbroken  bone,  opposite  the  seat  of 
fracture,  and  osseous  matter  is  sometimes  deposited  b}'^  it.  We  have 
specimens  illustrating  this  point  in  the  University  College  Museum. 

In  fractures  occurring  in  young  infants,  the  quantity  of  callus  thrown 
out  is  proportionally  very  great.  This  may  perhaps  be  owing  to  the 
difficulty  of  maintaining  such  fractures  in  steady  apposition,  and  partly 
also  to  the  activity  of  the  nutritive  process. 

If  the  fracture  be  not  well  reduced,  the  ends  not  being  in  proper 
apposition,  or  if  it  be  comminuted,  masses  of  new  bone  are  often 
deposited  as  buttresses  or  supports,  or,  enveloping  the  splinters,  con¬ 
solidate  them  with  the  rest  of  the  shaft.  So,  also,  when  the  fractured 
bones  are  not  kept  sufficiently  quiet  during  treatment,  the  neighboring 
parts  become  irritated,  and  provisional  callus  is  formed.  Hence,  as 
Paget  has  remarked,  we  commonly  find  this  deposit  in  fractures  of  the 
ribs,  which  are  kept  in  constant  motion  by  the  respiratory  actions.  In 
impacted  fractures  there  is,  from  the  perfect  apposition  of  the  surfaces, 
but  little  callus  formed. 

From  all  this,  I  think  it  clear  that  in  simple  fractures  %\\q  promsional 
callus  is  deposited  principally  by  the  surrounding  soft  tissues,  and  also, 
to  a  certain  extent,  by  the  periosteum  and  medullary  canal,  its  quality 
being  dependent  on  the  amount  of  irritation  set  up  in  these  structures. 
The  definitive  callus,  on  the  other  hand,  is  directly  and  immediately 
formed  by  the  vessels  of  the  fractured  bone  itself,  and  the  comparative 
want  of  vascular  supply  to  this  tissue  may  account  for  the  slowness  of 
its  formation. 

Union  of  Compound  Fractures. — The  difference  between  the  union  of 
a  simple  and  of  a  compound  fracture  is  the  same  as  that  between  the 
healing  of  a  subcutaneous  and  an  open  wound.  In  the  one  case  the 
healing  process  takes  place  without  any  sensible  local  disturbance  or 
constitutional  derangement:  in  the  other,  it  is  accompanied  by  local 
inflammation  and  suppuration,  and  by  corresponding  febrile  reaction. 
In  the  one  case,  there  is  no  exciting  cause  for  the  develo[)ment  of 
secondary  disease ;  in  the  other,  the  local  mischief  is  extremely  apt  to 
generate  these  in  their  worst  forms,  of  eiysipelas,  inflammation  of  the 
absorbents  or  veins,  and  pyaemia.  In  compound  fractures,  union  takes 
place  by  the  ends  of  the  bone,  which  lie  bathed  in  the  pus  of  the  wound, 
granulating  and  throwing  out  plastic  matter,  which  becomes  directly 
converted  into  bone.  There  is  in  many  cases  but  little  provisional 
callus;  but  in  most  instances  a  large  quantity  of  accessory  osseous 
deposit  takes  place,  more  particularly  if  the  displacement  be  consider¬ 
able.  The  union  of  these  fractures  precisel}’^  resembles  that  of  a  wound 
in  the  soft  structures — by  granulation,  or  “second  intention;”  the  only 
difference  being  that  the  granulations  which  are  thrown  out  by  the  bone 
and  periosteum  develop  into  new  osseous  tissues  either  directly  or 
through  the  medium  of  an  antecedent  fibroid  transformation.  This 
process  necessarily  occupies  a  much  longer  time  than  that  which  is 
necessary  for  the  union  of  simple  fractures,  consolidation  not  being 


312 


FEACTUEES. 


effected  for  three  or  four  months,  and  often  being  very  considerably 
retarded  beyond  this  by  the  separation  of  necrosed  bone,  the  formation 
of  abscesses,  etc.  Rokitansky  and  some  other  pathologists  are  of 
opinion  that  superficial  exfoliation  of  that  layer  of  bone  which  is  bathed 
bj’  the  pus  takes  place,  and  that  it  is  after  this  is  separated  that  the 
granulations  spring  up,  in  which  the  new  bone  is  deposited :  but  I  think 
that  it  admits  of  very  considerable  doubt  whether  this  process  of  necrosis 
goes  on  in  all  cases  of  compound  fracture. 

Union  of  fractures,  like  all  other  vital  actions,  takes  place  more  readily 
and  much  more  quickl}’  in  the  earl}^  periods  of  life  than  at  a  more  advanced 
age,  and  is  always  more  speedily  accomplished  in  the  upper  than  in  the 
lower  extremities. 

Treatment  of  Simple  Fractures. — In  conducting  the  treatment 
of  a  fracture,  the  object  of  the  Surgeon  should  be  not  only  to  obtain  a 
sound  and  strong  limb,  but  one  that  presents  as  little  deformity  and 
trace  of  former  injury  as  possible.  In  order  to  accomplish  this,  the 
broken  ends  of  the  bone  must  be  brought  into  as  perfect  apposition  as 
possible,  the  recurrence  of  displacement  must  be  prevented,  and  the 
local  and  constitutional  condition  of  the  patient  properly  attended  to. 

When  the  Surgeon  is  called  to  a  person  who  has  met  with  a  fracture, 
if  it  be  a  severe  one  of  the  upper  extremity,  or  of  any  kind  of  the  lower 
limbs,  he  must  see  that  the  bed,  on  which  the  patient  may  have  to 
remain  for  some  weeks,  is  properly  prepared,  by  being  made  hard,  flat, 
and  firm,  and,  if  possible,  covered  with  a  horse-hair  mattress.  The 
Surgeon  must  then  superintend  the  removal  of  the  patient’s  clothes, 
having  them  ripped  along  the  seams,  so  that  they  may  be  taken  off  with 
as  little  disturbance  as  possible  to  the  injured  part.  He  next  proceeds 
to  the  examination  of  the  broken  limb,  using  every  possible  gentleness 
consistent  with  acquiring  a  proper  knowledge  of  the  fracture.  After  he 
has  satisfied  himself  upon  this  point,  the  limb  should  be  laid  upon  a  soft 
pillow,  until  any  necessary  apparatus  has  been  prepared. 

Reduction. — When  all  has  been  got  ready,  the  reduction  of  the  fracture, 
or  the  bringing  the  fragments  into  proper  apposition,  must  be  proceeded 
with.  This  should,  if  possible,  always  be  done  at  once.,  not  onl}^  lest  any 
displacement  that  exists  may  continue  permanently — the  muscles,  after 
a  few  days,  becoming  shortened,  rigid,  and  unyielding,  not  allowing 
reduction  to  be  effected  without  the  employment  of  much  force — but 
also  with  the  view  of  preventing  irritation  and  mischief  to  the  limb,  by 
the  projection  of  the  sharp  and  jagged  ends  of  bone  into  the  soft  struc¬ 
tures.  A  great  deal  of  time  is  sometimes  lost,  and  very  unnecessary 
pain  inflicted  upon  the  patient,  and  great  irritation  set  up  in  the  limb, 
by  the  Surgeon  leaving  the  fracture  unreduced  on  a  pillow  for  several 
days,  and  appl3dng  evaporating  lotions  to  take  down  the  swelling  and 
avert  the  threatened  inflammation,  which  are  consequences  of  the  non¬ 
reduction  of  the  broken  bone.  The  application  of  cold  lotions,  irrigation, 
etc.,  in  compound  or  even  in  simple  fractures  is  decidedly  injurious.  It 
lowers  the  vitality  of  the  part,  retards  union,  and  occasions  oedema. 
By  early  reduction  we  ma}’’  sometimes  prevent  a  sharp  fragment  from 
perforating  the  skin,  and  thus  rendering  a  simple  fracture  compound,  or 
lacerating  muscles  and  nerves,  inducing  perhaps  traumatic  delirium,  and 
certainly  undue  local  inflammatory  and  spasmodic  action. 

The  great  cause  of  displacement  in  fractures  has  already  been  stated 
to  be  muscular  contraction;  hence,  in  effecting  reduction  of  a  fracture 
and  in  removing  the  displacement,  our  principal  obstacle  is  the  action  of 
the  muscles  of  the  part.  This  must  and  always  may  be  counteracted,  by 


PREVEXTIOX  OF  RETURX  OF  DISPLACE  MEXT.  813 


properly  relaxing  them  by  position ;  so  soon  as  this  is  done,  the  bony 
fragments  will  natiirall}’  fall  into  place ;  but  no  amount  of  extension  and 
of  counter-extension  can  bring  these  into  position,  and  much  less  retain 
them  there,  unless  all  muscular  influence  be  removed.  In  ordinaiy  frac¬ 
tures,  no  force  is  necessaiy  or  should  ever  be  emplo3’ed  for  accomplishing 
this;  but  attention  to  the  attachment  of  the  muscles  of  the  limb  and 
proper  relaxation  of  them  is  all  that  is  required.  In  impacted  fractures 
it  is  occasionally  necessaiy  to  use  force  in  order  to  disentangle  the 
fragments,  but  this  is  the  only  form  of  fracture  in  which  its  emplojunent 
is  justifiable.  In  effecting  the  reduction,  not  only  must  the  length  of  the 
limb  be  restored,  but  its  natural  curves  must  not  be  obliterated  b^'  making 
it  too  straight. 

Prevention  of  Return  of  Bi?. placement . — After  the  reduction  has  been 
accomplished,  means  must  be  taken  to  prevent  the  return  of  the  dis¬ 
placement ;  for,  if  the  parts  be  left  to  themselves,  muscular  action,  or 
the  involuntary  movement  of  the  patient,  will  be  certain  to  bring  about 
a  return  of  the  fault}"  position.  In  many  cases,  it  is  exceedingly  difficult, 
for  the  first  few  days,  to  keep  the  ends  of  the  bone  in  place,  in  consequence 
of  spasmodic  movement  of  the  muscles  of  the  limb,  or  of  restlessness  on 
the  part  of  the  patient.  About  this,  however,  the  Surgeon  need  not  be 
anxious,  as  no  union  takes  place  for  the  first  week  or  ten  days ;  at  the 
expiration  of  that  time  the  muscles  will  have  probably  lost  their  irrita¬ 
bility,  and  the  patient  have  become  accustomed  to  his  position,  so  that 
with  a  little  patience,  or  by  varying  the  apparatus  and  the  position  of 
the  limb,  good  apposition  may  be  maintained. 

The  return  of  displacement  is  prevented,  and  the  proper  shape  and 
length  of  the  limb  are  maintained,  by  means  of  bandages^  splints^  and 
special  apparatus  of  various  kinds.  In  applying  these,  care  should  be 
taken  not  to  exert  any  undue  pressure  on  or  forcible  entension  of  the 
limb.  Pads  and  compresses  of  all  kinds  should,  if  possible,  be  avoided  ; 
they  do  no  good  that  cannot  be  effected  by  proper  position,  and  even 
occasion  serious  mischief  by  inducing  sloughing  of  the  integuments,  over 
which  they  are  applied.  Screw-apparatus  has  been  invented  with  the 
view  of  forcing  fragments  into  proper  position,  but  nothing  can  be  more 
unsurgical  and  unscientific  than  such  barbarous  contrivances. 

Ill  cases  in  which  there  is  much  tendency  to  a  return  of  the  displace¬ 
ment,  it  has  been  recommended  to  divide  the  tendons  of  some  of  the 
stronger  muscles  inserted  into  the  lower  fragment.  This,  however,  can 
very  rarely  be  necessary ;  and  in  those  cases  in  which  I  have  done  it,  or 
seen  it  done,  no  material  benefit  has  resulted. 

The  Bandages  used  for  fractures  should  be  the  ordinary  gray  calico 
rollers,  about  three  finger-breadths  in  width,  and  of  sufficient  length. 
In  applying  them,  especial  care  must  be  taken  that  the  turns  press  evenly 
upon  every  part,  and  that  the  bandage  be  not  applied  too  tightly  in  the 
first  instance.  Xo  bandage  should  be  applied  under  the  splints,  more 
particularly  at  the  flexures  of  joints,  and  care  must  be  taken  that  the 
limb  be  not  bent,  or  its  position  otherwise  materially  altered,  after 
bandages  have  been  applied.  A  bandage  under  the  splints  is  not  only 
useless,  but  highly  dangerous,  by  inducing  risk  of  strangulation.  Xo 
bandage  should  be  applied  to  the  part  of  the  limb  that  is  the  seat  of 
fracture.  The  part  below  the  fracture  may  advantageously  be  bandaged, 
in  order  to  prevent  oedema;  thus,  in  fracture  of  the  humerus,  the  fingers 
and  forearm  may  be  bandaged  with  this  view,  but  no  turns  of  the  roller 
should  be  brought  above  the  elbow.  This  point  of  practice  I  consider 
most  important,  as  the  application  of  a  bandage  to  the  immediate  seat 


814 


•  FEACTUKES. 


of  fracture  not  only  causes  great  pain  and  disturbance  of  the  limb,  but 
danger  of  gangrene.  When  once  a  fractured  limb  has  been  ‘‘  put  up,”  the 
less  it  is  disturbed  the  better.  No  good  can  possibly  come,  but  a  great 
deal  of  pain  must  necessarily  result  to  the  patient,  from  meddling  with  it. 
The  Surgeon  should  alwa^^s  bear  in  mind  that,  in  the  treatment  of  a 
fractured  bone,  he  can  do  absolutely  nothing  to  promote  union,  beyond 
placing  it  in  a  good  and  eas}^  position.  Nature — the  natural  reparative 
action  of  the  body — solders  the  bone  together:  and  the  less  the  Surgeon 
interferes  with  the  natural  processes  of  repair,  the  more  satisfactorily 
will  union  be  accomplished.  But  it  is  requisite  to  examine  the  limb  from 
time  to  time  during  the  treatment,  and  especiall}^  about  the  second  or 
third  week,  when  union  is  commencing,  in  order,  if  necessary,  to  correct 
displacement.  In  the  earlier  stages,  supervision  is  necessary  lest  the 
bandage  be  too  tight;  and,  if  the  patient  complain  of  any  pain  or  numb¬ 
ness,  or  if  the  extreme  part  look  blue  and  feel  cold,  the  bandage  must 
be  immediately  removed  ;  for,  though  the  apparatus  have  not  been  applied 
tightly,  swelling  of  the  limb  may  come  on  from  various  causes,  to  such 
an  extent  as  to  produce  strangulation  and  consequent  gangrene  of  it, 
as  I  have  seen  happen  in  at  least  three  instances,  the  limb  requiring 
amputation  in  each  case  (Fig.  125).  It  is  remarkable,  that  the  whole  of 
a  limb  will  fall  into  a  state  of  gangrene  in  these  circumstances,  with  but 
little  pain,  and  often  with  sliglit  constitutional  disturbance,  the  parts 
having  their  sensibility  deadened  by  the  gradual  congestion  and  infiltra¬ 
tion  of  the  tissues.  When  such  an  unfortunate  accident  happens, 
recourse  must  be  had  to  immediate  amputation.  Before  applying  the 
apparatus  in  a  case  of  fracture,  and  as  often  as  it  is  taken  off,  it  is  a 
good  plan  to  sponge  the  limb  with  warm  soap  and  water,  which  prevents 
the  itching  that  otherwise  occurs  and  is  sometimes  verj^  troublesome. 

The  Splints  that  are  used  in  cases  of  fracture  are  of  various  kinds. 
Tin,  wood,  leather,  and  gutta-percha,  are  the  materials  usually  employed. 
For  some  kinds  of  fracture,  special,  and  often  very  complicated  apparatus, 
is  very  generally  used;  but  the  Surgeon  should  never  confine  himself  to 
one  material,  or  one  exclusive  mode  of  treating  these  injuries,  as  in  differ¬ 
ent  cases  special  advantages  may  be  obtained  from  different  kinds  of 
splints.  Wood  and  tin  are  principally  employed  in  the  lower  extremity, 
where  great  strength  is  required  to  counteract  the  weight  of  the  limb 
and  the  action  of  its  muscles ;  and  care  must  be  taken  to  pad  very 
thoroughly  splints  made  of  these  materials.  Leather,  gutta-percha,  and 
pasteboard,  are  more  commonly  useful  in  fractures  of  the  upper  extremity, 
though  they  may  not  unfrequently  be  employed  with  advantage  in  the 
lower  limbs.  In  applying  them,  a  pattern  should  first  be  cut  out  in  brown 
paper,  of  the  proper  size  and  shape ;  the  material  must  then  be  softened 
by  being  well  soaked  in  hot  water,  and  moulded  on  to  the  part  whilst 
soft:  as  soon  as  it  has  taken  the  proper  shape,  it  should,  if  leather  or 
gutta-percha  be  used,  be  hardened  by  being  plunged  into  cold  vinegar 
and  water  ;  the  pasteboard  must  be  allowed  to  dry  of  itself.  Its  edges 
may  then  be  pared  and  rounded,  and  its  interior  lined  with  wash-leather 
or  lint.  These  splints  have  the  advantage  of  great  durability,  cleanli¬ 
ness,  and  lightness.  The  material  of  which  the  splint  is  composed  is  of 
less  consequence  than  its  mode  of  application.  There  are  two  points 
that  require  special  attention  in  this  respect:  1,  that  the  splint  be  suffi¬ 
ciently  broad  to  extend  to  the  exterior  of  the  limb,  and  not  to  press  into 
it;  and,  2,  that  it  embrace  securely  and  fix  steadily  the  two  joints  con¬ 
nected  with  the  fractured  bone;  if  the  thigh,  the  hip,  and  knee;  if  the 


STARCHED  BANDAGE. 


815 


leg,  the  knee  and  ankle.  From  want  of  attention  to  this  point  of 
practice  much  trouble  is  often  occasioned  in  keeping  the  fragments  in 
steady  apposition,  and  much  deformity  will  often  result.  It  is  impossible 
to  keep  the  fragments  perfectly  immobile,  and  in  close  and  accurate 
apposition,  unless  this  veiy  important  point  be  attendee!  to. 

Special  apparatus  should  be  employed  as  little  as  possible  in  the 
treatment  of  fractures.  It  is  scarcely  ever  necessary  in  simple  fracture, 
and  is  far  more  cumbersome  and  costl}^  than  the  means  above  indicated, 
which  are  all  that  can  be  required.  I  have  no  hesitation  in  saying,  that 
a  Surgeon  of  ordinary  ingenuit}’  and  mechanical  skill  ma^"  be  fully 
prepared  to  treat  successfully  every  fracture  to  Avhicli  he  can  be  called, 
by  having  at  hand  a  smooth  deal  plank  half  an  inch  in  thickness,  and  a 
sheet  of  gutta-percha,  undressed  sole-leather,  or  pasteboard,  to  cut  into 
splints  as  required. 

To  the  simple  means  above  described  the  Starched  Bandage  is  an  in¬ 
valuable  addition.  Although  various  plans  of  stiffening  and  fixing  the 
bandages  in  cases  of  fracture,  b}’  smearing  them  with  white  of  eggs, 
with  gum.  plaster  of  Paris,  etc.,  have  been  employed  at  various  times,  it 
is  only  of  late  years  that  the  full  value  of  the  starched  bandage  has  been 
recognized  by  Surgeons,  chiefly  through  the  practice  and  writings  of 
Baron  Seutin. 

The  advantages  of  the  starched  bandage  in  the  treatment  of  fractures,  as 
well  as  in  many  other  injuries  and  diseases,  consist  in  its  taking  the  shape 
of  the  limb  accurately  and  readily,  and  maintaining  it  by  its  solidity;  in 
its  being  light,  inexpensive,  and  easily  applied,  with  materials  that  are 
always  at  hand.  It  secures  complete  immobility  of  the  limb  in  the  posi¬ 
tion  in  which  it  dries.  The  joints  in  the  neighborhood  of  the  fractured 
bone  are  securely  fixed,  and  the  perfect  adaptation  or  moulding  of  the 
apparatus  to  the  inequalities  of  the  limb  prevents  all  movement.  Thus 
it  becomes  a  powerful  and  efficient  extending  apparatus,  maintaining 
accurately  not  only  the  length  but  the  normal  curves  of  the  limb.  From 
its  lightness,  it  possesses  the  veiy  great  and  peculiar  advantage  in  frac¬ 
tures  of  the  lower  extremit}’,  of  allowing  the  patient  to  remain  up  and 
to  move  about  upon  crutches  during  nearly  the  whole  of  the  treatment; 
thus  by  rendering  confinement  to  bed  unnecessary,  it  prevents  the  ten- 
denc}"  to  those  injurious  consequences  that  often  result  from  these  inju¬ 
ries ;  and,  by  enabling  the  patient  to  keep  up  his  health  and  strength  by 
open-air  exercise,  it  facilitates  the  consolidation  of  the  fracture.  In 
addition  to  this,  the  patient  will  often  be  able  to  carry  on  his  business 
during  treatment.  emplo3'ing  the  starched  bandage  in  the  wa}’  that 
will  be  immediately  pointed  out,  I  scarcely  ever  find  it  necessary  to  keep 
patients  in  bed  with  simple  fractures  of  the  thigh  for  more  than  six  or 
seven,  or  of  the  leg  for  more  than  three  or  four  daj^s,  thus  saving  much 
of  the  tediousness  and  danger  of  the  treatment. 

The  following  is  the  mode  of  appl3ing  this  apparatus  that  is  adopted 
at  the  [Jniversit3’’  College  Hospital,  and  which  will  be  found  to  answer 
well.  The  whole  limb  is  enveloped,  as  recommended  b3’'  Burggraeve,  of 
Ghent,  in  a  la3’er  of  cotton  wadding,  which  is  thickl3’-  laid  along  and 
over  the  osseous  prominences  ;  this,  being  elastic,  accommodates  itself  to 
the  subsequent  diminution  in  size  of  the  limb,  and  keeps  up  more 
equable  pressure.  Over  the  cotton-wadding  are  laid  splints  of  thick  and 
coarse  pasteboard  soaked  in  thin  starch,  properl3’  shaped  to  fit  the  limb. 
The  pasteboard  should  be  soft,  not  milled,  and  be  doubled  and  torn 
down  not  cut,  as  in  this  way  the  edges  are  not  left  sharp.  If  much 
strength  be  not  required,  as  in  children,  or  in  some  fractures  of  the  upper 


816 


FEACTU  RES. 


Fig.  120. 


extremit}^,  a  few  slips  of  brown  paper,  well  starched,  may  be  substituted 
for  the  pasteboard.  A  bandage  saturated  with  thick  starch  is  now 
firml}^  applied ;  and  lastl^^,  this  is  covered  by  another  dry  roller,  the 
inner  sides  of  the  turns  ot  which  may  be  starched  as  it  is  laid  on.  No 
roller  or  bandage  should  be  applied  directly  to  the  fractured  part  under 
the  splints:  its  application  is  always  painful  and  difficult,  and  it  is 
attended  with  danger  ot  constriction  or  abrasion.  Both  the  pasteboard 

splints  and  the  starched  bandage  should 
always  include  the  two  joints  above  and 
below  the  fracture,  so  that  complete 
immobilit}’  of  the  fragments  may  be 
secured:  the  hip  and  knee  when  the 
thigh  is  broken ;  the  knee  and  ankle 
when  the  leg  is  fractured.  During  the 
application  of  this  apparatus,  extension 
must  be  kept  up  by  an  assistant,  so  as 
to  hold  the  fracture  in  position ;  and, 
until  the  starch  is  thoroughly  dried, 
which  usually  takes  place  from  thirty  to 
fifty  liours,  a  wooden  splint  may  be  ap¬ 
plied  to  the  limb,  so  as  to  keep  it  to  its 
proper  length  and  shape.  The  diying  of 
the  starch  may, if  necessaiy,be  hastened 
by  the  application  of  hot  sand-bags  to 
the  apparatus.  After  the  bandages  have 
become  quite  diy,  the  temporary  splint 
must  be  removed,  and  the  patient  may 
then  be  allowed  to  move  about  on 
crutches,  taking  care,  of  course,  to  keep 
the  injured  limb  well  slung  up,  and  not 
to  bear  upon  it,  or  to  jar  it  against  the 
ground  (Fig.  120).  In  the  course  of 
about  three  or  four  days  after  its  appli¬ 
cation,  the  apparatus  will  usuall}^  be 
found  to  have  loosened  somewhat,  the 
limb  appearing  to  ^irink  wuthin  it.  In 
these  circumstances  it  becomes  neces¬ 
sary  to  cut  it  up  with  a  pair  of  Seutin’s  pliers,  sucli  as  are  represented  in 
Fig.  121.  This  section  must  be  made,  as  represented  in  Fig.  122,  along  the 


starched  Bandage  applied  to  Fractured 
Thigh. 


Fig.  121. 


Seutin’s  Pliers. 


more  muscular  part  of  the  limb,  so  that  the  skin  covering  the  bones  be  not 
injured  ;  and,  after  paring  the  edges  of  the  splint,  it  must  be  reapplied 
by  means  of  tapes  or  a  roller  In  trimming  the  edges  of  the  splint,  it 
should  not  be  removed  from  the  limb.  If  the  fracture  be  compound,  a 


STARCHED  BANDAGE. 


317 


Fig.  122. 


Application  of  Seutin’s  Pliers  to  Starched  Bandage. 


Fig.  123. 


trap  may  be  cut  in  the  apparatus  opposite  the 
seat  of  injuiy,  through  which  the  wound  may  be 
dressed  (Fig.  123). 

Although  fully  recognizing  the  great  advan- 
tasres  to  be  obtained  bv  treating:  fractures  on  this 
plan,  and  employing  the  starched  bandage  in 
almost  every  case  that  came  under  m}^  care,  I 
did  not  at  first  think  that  it  was  a  safe  practice 
to  have  recourse  to  it  during  the  early  stages  of 
fracture ;  until,  indeed,  the  swelling  of  the  limb 
had  begun  to  subside.  I  therefore  never  applied 
it  until  the  sixth,  eighth,  or  tenth  day,  keeping 
the  limb,  until  this  time,  properh'  reduced  upon 
a  splint,  veiy  lightlj’  bandaged,  and  wet  with 
cold  evaporating  lotions ;  fearing  that,  if  the 
bandage  were  applied  at  too  early  a  period,  the 
inflammatoiy  turgescence  of  the  limb  might  give 
rise  to  a  slow  stran2:ulation  of  it  under  the 

O 

apparatus. 

During  many  j^ears,  however,  I  have  employed 
Seutin’s  plan  in  several  hundreds  of  fractures  of 
all  kinds,  putting  the  limb  up  in  the  starched 
apparatus  immediately  after  the  reduction  of  the 
fracture.  I  have  found  the  practice  an  extremely 
successful  one,  even  in  fractures  of  the  thigh ;  so 
much  so,  that  at  the  Hospital  I  now  rarely  use 

any  other  plan  of  treatment  than  the  “  movable-immovable”  apparatus 
in  some  form  varying  with  the  fashion  of  the  day;  and,  indeed,  the  more 
experience  I  have  of  it  the  more  satisfied  am  I  with  the  results  obtained 
b3’  it.  The  moderate  pressure  of  the  bandages,  aided  probablj’  b^^  the 
great  evaporation  which  goes  on  during  the  drying  of  so  extensive  and 
thick  a  mass  of  wet  starch,  and  which  produces  a  distinct  sensation  of 
cold  in  the  limb,  takes  down  the  extravasation  most  effectuallj^,  and 
enables  the  patient  usualh’  to  leave  his  bed  about  the  third  da}’  after 
the  injury,  when  the  fracture  is  in  the  leg  or  ankle,  and  about  the  sixth 
when  it  is  the  thigh  that  is  broken ;  so  that  we  now  treat  all  patients 
with  simple  fractures  of  the  leg,  and  many  with  fractures  of  the  thigh, 
especially  children,  as  out-patients. 

From  no  other  means  of  treatment  have  I  seen  such  satisfactory  results 
in  cases  of  fractured  thigh,  as  from  the  starched  apparatus;  patients 
having  frequently  been  cured  without  any  shortening,  with  the  preserva- 


Starched  Bandage:  Trap  left 
for  Dressing  Wound. 


818 


FRACTURES. 


tion  of  the  natural  curve  of  the  bone,  and  without  confinement  to  bed 
after  the  first  week. 

In  compound  fractures  also  of  the  leg,  and  even  of  the  thigh,  I  have 
obtained  most  satisfactoiy  results  from  this  means.  In  compound  frac¬ 
tures  of  the  leg,  I  have  seen  the  patient  walking  about  on  crutches  as 
earh’  as  the  tenth  or  fourteenth  day,  the  limb  being  securely  put  up  in 
starch;  and  have  more  frequently  succeeded  in  getting  union  of  the 
wound,  and  consequent!}’  in  converting  the  compound  into  a  simple  frac¬ 
ture,  b}’  putting  up  the  limb  in  this  apparatus  than  in  an}’  other. 

Glue  may  be  substituted  for  starch  in  stiffening  the  fracture  apparatus. 
The  glue  used  for  this  purpose  should  be  prepared  by  making  a  strong 
solution  of  the  best  French  glue,  and  then  adding  to  this  about  one-eighth 
of  spirits  of  wine.  This  mixture  may  then  be  thickly  brushed  over  the 
bandage.  After  drying,  the  apparatus  should  be  cut  up,  trimmed,  and 
fixed  on  by  straps,  lacings,  or  bandages,  as  most  convenient.  It  pos¬ 
sesses  the  advantages  over  the  starched  bandage  of  drying  more  quickly, 
and  of  being  lighter  and  more  elastic,  but  it  is  not  so  strong  or  so  well 
adapted  for  purposes  of  support  when  the  whole  of  a  muscular  limb  or 
large  joints  have  to  be  included. 

The  Plaster  o  f  Paris  Bandage  may  sometimes  be  advantageously  used 
as  a  substitute  for  the  starched  apparatus.  It  may  be  applied  in  one  of 
the  three  following  wavs  : — 

1.  A  bandage  of  coarse  soft  muslin  has  dry  plaster  of  Paris  thoroughly 
rubbed  into  its  meshes;  it  is  then  rolled  up,  and  some  cold  water  is 
poured  ui)on  each  end  of  it  so  as  to  moisten  it  through.  A  dry  roller 
having  been  previously  applied  to  the  limb,  the  wetted  plaster  bandage 
is  smoothly  rolled  over  it,  the  Surgeon  taking  care  that  no  reverses  are 
made.  In  order  to  avoid  these,  it  may  be  applied  in  a  spiral  or  figure- 
of-8  manner  over  the  more  unequal  parts.  Slips  of  the  plaster  bandage 
should  also  be  laid  on  where  additional  strength  is  required,  and  the 
whole  well  wetted  from  time  to  time  during  the  application.  It  hardens 
in  the  course  of  a  few  minutes,  and,  as  it  dries,  forms  a  solid,  hard,  and 
light  casing  to  the  limb,  affording  excellent  support  to  the  fracture.  The 
plaster  bandage  possesses  the  advantage  over  the  starched  apparatus  of 
being  lighter,  and  especially  of  drying  and  hardening  very  quickly — 
qualities  which  render  it  invaluable  in  cases  in  which  it  is  necessary  to 
carry  patients  any  distance  immediately  after  the  setting  of  the  fracture. 

2.  Neudorfer  is  a  strong  advocate  for  the  employment  of  the  plaster 
of  Paris  bandage.  He  recommends  that  it  should  be  applied  imme¬ 
diately  (on  this  he  lays  great  stress),  in  the  following  way.  Compresses 
of  linen,  or  of  lint,  are  dipped  in  plaster  of  Paris  of  the  consistence  of  a 
common  poultice.  These  are  then  placed  longitudinally  on  the  limb, 
first  on  the  upper,  then  on  the  under  part.  A  few  turns  of  a  bandage 
keep  them  in  situ  till  the  plaster  is  set.  To  prevent  the  contiguous  edges 
from  adhering,  they  are  slightly  greased,  or  a  slip  of  greased  lint  is  put 
between  them. 

He  sometimes  uses  pieces  of  thin  wood,  like  veneer,  lined  with  cotton¬ 
wool  next  the  skin  ;  over  these  the  bandage,  saturated  with  the  plaster, 
is  ap})lied  by  circular  turns  in  the  usual  way.  In  applying  the  plaster 
bandage,  no  cotton-wool  or  other  soft  material  need  otherwise  be  laid 
between  it  and  the  skin.  The  bandage,  soaked  in  plaster  of  the  consist¬ 
ence  of  cream,  is  first  applied  in  a  circular  manner,  in  the  neighborhood 
of  the  fracture,  which  has  previously  been  reduced.  If  this  be  compound, 
the  wound  must  not  be  covered  by  the  turns  of  the  bandage.  Three  super¬ 
imposed  layers  are  usually  sufficient  to  give  stability.  The  same  method 


PLASTER  BANDAGES. 


319 


is  then  applied  to  the  bone  above  and  belovr  the  fracture.  The  bandage, 
if  properly’  ai)plied,  should  be  quite  firm  in  eight  minutes.  The  opening 
of  tlie  wound  is  then  to  be  covered  with  cotton-wool  of  sufficient  thick¬ 
ness  to  be  on  a  level  with  the  bandage;  and  over  this  must  be  fastened 
a  handkerchief  or  ordinary  bandage.  As  soon  as  the  whole  limb  has 
been  thus  covered  in,  a  diy  strip  of  simple  bandage  is  placed  along  its 
whole  length,  and  a  piece  of  wire  along  each  side  of  this;  and  the  whole 
is  then  smeared  and  smoothed  down  with  plaster  of  Paris.  While  the 
mixture  is  still  moist,  and  before  it  is  quite  set,  the  ends  of  the  wires  are 
drawn  up,  and  the  casing  is  thus  cut  through  by  two  narrow  furrows 
along  its  whole  length,  b}’  which  it  is  in  no  wa}-  weakened.  When  it  is 
necessary  to  remove  the  apparatus,  the  ends  of  the  dry  slip  of  bandage 
w’hich  lies  between  the  furrow's,  are  drawn  up  together,  and  a  lid  of  plaster 
of  Paris  is  removed.  The  subjacent  plastered  bandage  is  then  easilj'  cut 
through  by  scissors.  In  the  case  of  a  large  limb,  this  proceeding  may 
be  adopted  in  several  places,  so  that  the  apparatus  may  be  cut  into  as 
many  pieces  as  is  necessaiy. 

The  setting  of  the  plaster  may  be  retarded  b}'  the  addition  to  it  of 
solution  of  borax.  Thus  a  solution  of  1  part  to  12  of  the  w’ater  used  will 
retard  the  setting  fifteen  minutes;  of  1  to  8  will  retard  it  fifty  minutes, 
and  so  on. 

3.  The  method  of  apphdng  the  plaster  apparatus,  as  practised  in  the 
Bavarian  arm3'  during  the  Franco-German  War,  is  as  folio w  s :  Two  pieces 
of  flannel,  twent}'  inches  broad,  are  stitched  together  down  the  middle 
for  the  length  of  the  leg;  and  be3’ond  this  both  are  cut  through  in  the 
same  line  for  the  length  of  the  foot.  The  flannel  is  placed  under  the 
limb,  so  that  the  seam  reaches  from  the  ham  to  the  heel.  The  sides  of 
the  inner  piece  are  brought  together  over  the  leg,  and  fixed  in  front,  and 
along  the  sole,  b^'  harelip  pins  (bent  at  a  right  angle,  so  that  the}'  may 
be  easil}'  extracted  afterwards),  and  thus  a  closel}'  fitting  stocking  is 
formed.  The  sides  of  the  outer  piece  are  then  brought  forward  and  cut, 
so  that  each  may  overlap  the  middle  line  of  the  leg  and  sole  by  three- 
quarters  of  an  inch.  The  limb  is  then  laid  on  one  side  ;  and  while  the 
outer  piece  of  flannel  is  held  back,  a  laj'er  of  plaster  of  Paris  of  the  con¬ 
sistence  of  thick  cream  is  spread  evenl}',  to  the  thickness  of  half  an  inch, 
over  the  inner  piece,  and  made  to  pass  quite  to  the  seam  behind,  and 
the  line  of  junction  of  the  sides  of  the  inner  piece  in  front.  The  outer 


Fig.  124. 


Bavarian  Plaster  Splint:  adjustment  of  the  Flannel  Layers. 


piece  is  pressed  over  this  before  it  sets,  and  should  just  reach  the  middle 
line  in  front  and  along  the  sole.  When  this  has  set,  the  limb  is  turned 
over,  and  the  process  is  repeated  on  the  other  side.  The  pins  may  now 
be  removed.  The  seam  serves  as  a  hinge  ;  and,  when  the  whole  has  set, 
the  splint  may  be  taken  off,  the  edges  of  the  plaster  trimmed,  and  those 


820 


FEACTURES. 


of  the  inner  piece  of  flannel  cut  so  as  to  leave  sufficient  to  turn  over  and 
stitch  down  on  the  outer  piece.  The  splint  is  then  readjusted  and  fixed 
by  a  bandage  (Fig.  124). 

In  the  treatment  of  ordinary  simple  fractures  of  the  shafts  of  long 
bones,  the  following  are  the  chief  points  that  require  attention: — 

1.  To  effect  reduction  at  once,  and  with  as  little  disturbance  of  the 
limb  as  possible. 

2.  Not  to  apply  any  roller  to  the  part  of  the  limb  in  which  the  fracture 
is  situated,  nor  under  the  apparatus. 

3.  To  line,  pad,  or  wad  the  apparatus  thickly. 

4.  To  include  and  fix  in  the  apparatus  the  two  joints  connected  with 
the  injured  bone. 

5.  To  disturb  the  apparatus  as  seldom  as  possible. 

6.  To  use  starched  pasteboard  or  plaster  apparatus,  when  practicable, 
in  preference  to  any  more  special  form  of  appliance. 

Accidents  during  Treatment. — Various  accidents  are  liable  to 
occur  during  the  treatment  of  a  fracture  ;  some  of  these  are  general, 
others  special.  Amongst  the  more  general  accidents.  Tetanus,  Trau¬ 
matic  Delirium,  and  Erysipelas  may  be  mentioned  as  the  most  common. 
Amongst  the  more  special,  the  occurrence  of  Spasm  of  the  Muscles  of 
the  Limb,  Abscess,  (Edema,  Gangrene,  and  a  tendency  to  Pulmonary 
and  Cerebral  Congestion,  are  those  that  have  most  to  be  guarded  against. 

In  order  to  prevent  the  occurrence  of  these  conditions  the  general 
health  must  be  carefully  attended  to ;  the  bowels  being  kept  open,  the 
room  well  ventilated,  nourishing  diet  allowed,  and  long  confinement  to 
bed  avoided  by  the  use  of  a  “  movable-immovable’^  apparatus,  as  above 
described. 

The  treatment  of  the  more  general  accidents  presents  nothing  that 
need  detain  us  here ;  but  those  that  are  more  special  and  peculiar  to 
fractures,  require  consideration. 

Spasm  of  the  Muscles  of  the  Limb^  owing  to  the  irritation  produced 
by  the  fragments,  is  often  very  severe  so  long  as  the  fracture  is  left  un¬ 
reduced  ;  the  sharp  end  of  the  broken  bone  puncturing  and  irritating  the 
surrounding  muscles.  It  is  best  remedied  by  reduction,  and  the  main¬ 
tenance  of  the  fracture  in  proper  position  by  moderate  pressure  with  a 
bandage.  In  troublesome  cases,  compression  of  the  main  artery  of  the 
limb  has  been  recommended  by  Broca.  If  the  spasm  be  dependent  upon 
nervous  causes,  full  doses  of  opium  will  not  unfrequently  afford  relief. 
In  some  cases  it  is  of  a  permanent  character,  producing  considerable 
displacement  of  the  fragments.  In  these  circumstances,  division  of  the 
tendons  has  been  recommended;  but  this  practice  appears  to  be  an  un¬ 
necessarily  severe  one,  and  may  certainly  most  commonly  be  avoided  by 
attention  to  the  other  plans  of  treatment  which  have  been  suggested. 

Considerable  Extravasation  of  Blood  is  frequently  met  with  in  cases 
of  simple  fracture  causing  great  swelling  and  tension.  By  the  continuous 
application  of  cold  evaporating  lotions,  the  collection  is  usually  readily 
absorbed ;  and  the  Surgeon  should  never  be  tempted  by  any  feeling  of 
fluid  or  of  fluctuation  to  open  it,  as  he  would  thereb}^  infallibly  convert 
the  simple  into  a  compound  fracture,  and  give  rise  to  extensive  ill-con¬ 
ditioned  suppuration.  In  some  of  the  cases  of  extensive  extravasation, 
the  limb  appears  to  relieve  itself  of  the  serous  portion  of  the  blood 
effused,  by  the  formation  of  large  bullae  or  blebs,  which  may  be  punc¬ 
tured,  or  else  allowed  to  burst  and  subside,  without  any  material  incon¬ 
venience.  This  extravasation  very  rarely,  indeed,  runs  into  abscess  ;  if 
it  do,  it  must  of  course  be  opened,  and  treated  upon  ordinary  principles. 


ACCIDENTS  DURING  TREATMENT. 


821 


If  deeply  effused  it  may  lead  to  gangrene,  by  the  constriction  and  com¬ 
pression  which  it  exercises  on  the  vessels  of  the  limb. 

Oedema  and  Gangrene  of  the  Limb  (Fig.  125)  may  occur  after  fracture 
as  the  result  (1)  of  tight  bandaging  ;  (2)  of  the  swelling  of  the  limb  and 
compression  of  the  vessels  consequent  upon  extravasation  of  blood,  or  (3) 


Gangrene  of  Forearm  and  Hand  from  Tight  Bandaging. 


of  inflammatory  infiltration  causing  strangulation  within  a  bandage  that 
has  been  at  first  but  lightly  applied.  It  is  almost  invariably  the  conse¬ 
quence  of  the  pernicious  and  dangerous  practice  of  appljdng  a  bandage 
directly  to  the  limb  under  the  apparatus.  I  have  never  known  gangrene 
to  occur  after  fracture,  except  where  this  has  been  done.  If  the  splints 
be  well  wadded,  and  no  bandage  be  put  on  under  them,  it  is  almost  im¬ 
possible  that  an  undue  or  dangerous  amount  of  constriction  can  be 
exercised  on  the  limb,  so  as  to  interrupt  the  circulation  through  it.  I 
believe  that  this  accident  would  rareljq  if  ever,  occur,  if  the  Surgeon 
were  to  avoid  the  direct  application  of  a  bandage  to  the  limb,  however 
lightly,  in  fractures,  more  particularly  in  children.  The  danger  of  stran¬ 
gulation  is  especially  great  if,  as  happened  in  the  case  from  which  the 
accompan3dng  cut  is  taken,  the  limb  be  bandaged  whilst  straight,  and 
then  flexed,  as  the  bandage  will  then  cut  in  deeply  at  the  flexure  of  the 
joint,  and  certainly  destroy  the  vitalit}’’  of  the  part,  if  not  of  the  whole 
limb.  Even  if  no  direct  bandage  have  been  applied,  the  apparatus  should 
at  once  be  removed,  and  the  limb  examined,  whenever  the  patient  com¬ 
plains,  even  of  slight  uneasiness  ;  or,  indeed,  if  any  appearances  of  con¬ 
gestion  such  as  blueness,  coldness,  oedema,  or  vesications  of  the  fingers 
and  toes,  show  themselves.  If  it  be  left  on  be^’ond  this,  gangrene  will 
probably  set  in,  slow  strangulation  going  on  under  the  bandages  without 
much,  if  with  any,  pain.  Too  much  importance  must  not  be  attached  to 
the  mere  appearance  of  vesications.  The}^  will  often  occur  of  veiy  large 
size,  as  has  already’  been  stated,  as  a  consequence  of  the  raising  of  the 
cuticle  b}’-  the  transuded  serum  of  extravasated  blood.  It  is  only  when 
associated  wdtli  coldness  of  the  limb,  a  dusky  purple  hue,  and  a  putres¬ 
cent  odor,  that  the}’’  are  indicative  of  gangrenous  action.  An  excellent 
plan  of  judging  the  activity  of  the  circulation  in  a  fractured  limb  after 
it  has  been  put  up,  is  to  leave  the  ends  of  the  fingers  or  toes  uncovered 
by  the  bandage  ;  when,  by  pressing  upon  one  of  the  nails,  the  freedom 
of  the  circulation  may  be  ascertained  by  noticing  the  rapidity  with  which 
the  blood  returns  under  it.  Should  gangrene  unfortunately  have  oc¬ 
curred  as  the  result  of  tight  bandaging,  or  in  consequence  of  the  Surgeon 
neglecting  to  examine  the  limb,  and  thus  allowing  slow  strangulation  to 
set  in,  there  will  be  no  resource  but  to  amputate  above  the  line  of  de¬ 
marcation. 

VOL.  I _ 21 


322 


FRACTURES. 


In  fractures  occurring  in  old  people,  there  is  a  great  tendenc}’  to  Puh 
monary  and  Cerebral  Congestion^  partly  from  determination  of  blood, 
and  partly  as  a  consequence  of  the  long  confinement  required;  these 
fractures  commonly  prove  fatal  in  this  way.  The  use  of  the  starched 
bandage,  b}^  enabling  the  patient  to  move  about,  is  the  most  eflTectual 
preventive  of  these  accidents. 

Complicated  Fractures. — Fractures  may  be  comjolicated  with 
various  important  local  conditions.  Extravasation  of  blood  into  the 
limb,  from  a  wound  of  some  large  vessel,  may  go  on  to  so  great  an 
extent  as  to  occasion  strangulation  of  the  tissues ;  if  not  checked  by 
position  and  cold  applications,  it  ma}"  give  rise  to  gangrene,  and  demand 
amputation.  In  other  cases,  again,  the  soft  parts  in  the  vicinity-  of  the 
fracture  may  be  contused  to  such  a  degree  that  they  rapidl}"  run  into 
slough,  thus  rendering  it  compound;  or  a  wound  may  exist,  not  com¬ 
municating  with  the  broken  bone,  but  requiring  much  modification  of 
treatment,  and  special  adaptation  of  apparatus. 

One  of  the  most  serious  complications  of  a  simple  fracture  is  un- 
doubtedl}"  the  Rupture  of  the  Main  Artery  of  the  limb  opposite  the  seat 
of  fracture,  or  its  wound  by  one  of  the  fragments  of  broken  bone.  This 
accident  chiefl}'  occurs  in  fractures  of  the  lower  part  of  the  femur  or 
upper  part  of  the  tibia;  the  i^opliteal  in  one  case,  and  the  posterior 
tibial  in  the  other,  being  the  vessels  wounded.  The  symptoms  consist 
in  the  rapid  formation  of  an  uniform  elastic  tense  swelling  of  the  limb, 
with  obscure  pulsation  or  thrill,  opposite  the  seat  of  injury,  and  cessa¬ 
tion  of  pulsation  in  the  arteries  of  the  ankle,  with  coldness  and  numbness 
of  the  foot  and  lower  part  of  the  leg.  If  tlie  posterior  tibial  be  the 
vessel  injured,  the  circulation  in  the  arteries  of  the  foot  may  return  after 
a  da}’  or  two,  and  the  coldness  and  numbness  may  lessen.  If  it  be  the 
popliteal  that  is  injured,  no  such  amelioration  will  take  place,  but  the 
diffused  aneurism  in  the  ham  will  increase,  the  circulation  will  become 
more  and  more  impeded,  and  gangrene  will  result. 

What  should  be  the  treatment  of  such  a  case  as  this?  The  Surgeon 
has  three  alternatives. 

1.  The  case  may  be  treated  as  one  of  open  arterial  wound,  the  tumor 
laid  open,  and  the  injured  vessel  ligatured  at  the  seat  of  wound.  The 
objections  to  this  treatment  are,  that  a  large  cavity  is  opened,  which 
must  suppurate,  and  will  probably  slough ;  that  the  fracture  is  rendered 
a  compound  one  of  the  worst  kind  ;  and  that  the  securing  the  artery  is, 
in  any  circumstances,  extrerael}"  difficult,  and  indeed  uncertain,  entailing 
such  an  amount  of  disturbance  of  the  soft  parts  as  seriously  to  imperil 
the  vitalit}'  of  the  limb. 

2.  The  circulation  through  the  femoral  artery  may  be  arrested  by 
compression  or  ligature  of  the  vessel.  I  am  not  aware  that  compression 
has  ever  been  tried  in  a  case  of  diffused  traumatic  aneurism ;  but  there 
can  be  no  reason  wh}’  the  effects  of  pressure  upon  the  arteiy,  by  means 
of  Carte’s  or  some  other  proper  compressor,  should  not  be  tried  before 
proceeding  to  more  severe  measures.  Should  it  not  succeed,  the  artery 
may  be  tied  in  Scarpa’s  triangle.  But  this  should  only  be  done  in  those 
cases  in  which,  notwithstanding  the  existence  of  diffused  traumatic 
aneurism  in  the  ham,  the  pulsation  has  returned  in  the  arteries  of  the 
foot,  and  the  warmth  and  sensibility  of  the  member  have  been  in  part  at 
least  restored.  If  these  evidences  of  a  return  of  circulation  through  the 
anterior  tibial  have  not  taken  place,  it  will  be  worse  than  useless  to 
ligature  the  femoral,  as  gangrene  must  inevitabty  ensue. 

3.  Amputation  of  the  thigh  may  be  performed.  This  severe  measure 


COMPLICATED  FRACTURES. 


323 


need  not  be  carried  out  at  once.  The  Surgeon  may  wait  a  clay  or  two 
and  watch  the  progress  of  events.  If  he  find  that  there  is  no  sign  of 
restoration  of  pulsation  in  the  arteries  of  the  foot,  that  the  coldness  and 
numbness  of  the  limb  continue  to  increase,  and,  in  fact,  that  gangrene 
is  impending,  then  the  sooner  he  amputates  the  better  for  the  patient’s  • 
safety.  If  the  artery  have  been  tied,  and  gangrene  results,  the  limb 
ought  at  once  to  be  removed. 

To  sum  up,  I  would  advise,  in  a  case  of  diffused  traumatic  aneurism 
arising  from  and  complicating  a  simple  fracture  of  the  lower  extremity : 

1.  Not  to  open  the  tumor  and  search  for  the  artery  at  the  seat  of  wound; 

2.  To  compress  or  tie  the  femoral,  if  pulsation  have  returned  or  con¬ 
tinue  in  the  arteries  of  the  foot;  but,  should  pulsation  not  have  returned 
within  two  or  three  days,  should  gangrene  be  imminent,  or  actually 
have  set  in,  or  should  the  artery  have  been  ligatured,  and  mortification 
have  ensued,  to  amputate  high  in  the  thigh  without  further  dela}".  It 
will  thus  be  seen  that,  in  a  diffused  traumatic  aneurism  complicating  a 
fracture  of  the  bones  of  the  lower  extremity,  the  ordinary  treatment  of 
diffused  traumatic  aneurism  must  be  departed  from,  for  these  reasons: 

1.  That,  owing  to  the  great  displacement  of  parts  and  laceration  of  soft 
structures  consequent  on  the  fracture,  it  would  ^be  almost  impossible  to 
find  the  injured  vessel;  and,  2.  That,  if  it  were  found,  the  opening  up  of 
the  limb  would  leave  a  large  ragged  wound  communicating  widely  with 
the  broken  bones,  and  leading  to  the  worst  form  of  compound  fracture, 
with  an  amount  of  disorganization  in  the  limb  that  could  scarcely  be 
recovered  from. 

However  extensively  a  bone  may  be  comminuted,  good  union  will 
take  place  provided  the  fracture  be  simple;  that  is,  provided  no  Wound 
exist  in  the  Limb  by  ivhich  Air  may  gain  admission  to  the  fracture  or  to 
the  soft  parts  implicated  in  it.  I  have  seen  the  lower  end  of  the  femur 
crushed,  as  if  bj^  a  sledge-hammer,  into  a  multitude  of  fragments ;  and 
yet  excellent  union  resulted,  the  fracture  being  simple,  with  no  breach 
even  of  integument.  In  such  a  case  as  this,  if  there  had  been  the 
smallest  wound  to  admit  air  into  the  limb,  suppurative  action  of  the 
most  extensive  and  destructive  character  would  undoubtedly  have  set 
in,  and  the  patient’s  limb  at  least,  if  not  his  life,  would  have  been  lost. 
It  is  impossible  to  overestimate  the  advantage  of  an  injury  of  this  kind 
being  subcutaneous. 

A  serious  complication  of  simple  fractures  consists  in  their  Implicating 
a  Joint.  The  fracture  ma}’"  extend  into  a  neighboring  articulation,  and 
thus  give  rise  to  considerable  inflammatory  action ;  in  strumous  subjects 
this  maj’^  lead  to  ultimate  disorganization  of  the  articulation,  requiring 
excision,  which  I  have  several  times  had  occasion  to  perform  in  these 
cases.  But  in  healthy  individuals  a  large  articular  surface  may  be 
traversed  by  lines  of  fracture  in  several  directions,  without  material 
inconvenience  resulting.  This  we  see  in  impacted  fractures  of  the 
condyles  of  the  femur  or  of  the  lower  end  of  the  radius.  In  several 
instances  of  this  kind  in  which  I  have  examined  the  limb  after  death, 
no  sign  of  disease  of  the  part  has  been  manifested  beyond  a  moderate 
amount  of  injection  of  the  ligaments ;  the  fractured  incrusting  cartilage 
uniting  by  plastic  matter,  and  the  synovia  being  clear  and  free  from 
inflammatory  exudation.  But,  although  union  of  fractures  extending 
into  articulations  takes  place  readily  enough,  it  cannot  be  expected  that 
the  patient  will  recover  as  mobile  a  joint  as  if  the  fracture  had  merely 
traversed  the  shaft.  In  fact,  in  the  majority  of  these  cases,  the  patient 
will  be  left  with  a  joint  that  is  weak,  stiff,  and  painful ;  and,  if  the 


1 


324  FRACTUKES. 

lower  extremity,  unable  to  support  the  weight  of  the  body  for  some 
considerable  time.  Possibl}",  also,  in  many  of  these  instances  an  im¬ 
paired  joint  will  be  left  through  life,  as  the  necessary  and  unavoidable 
result  of  the  injury,  though  not  unfrequently  unjustly  attributed  to 
negligence  and  want  of  skill  on  the  part  of  the  Surgeon. 

The  occurrence  of  Dislocation  at  the  same  time  as  the  fracture,  and 
from  the  same  violence  that  occasions  this,  often  occasions  great  diffi¬ 
cult}"  to  the  Surgeon,  as  it  becomes  necessary  to  reduce  the  dislocated 
joint  before  the  fracture  is  consolidated.  In  several  cases  of  this 
description  which  have  fallen  under  my  care,  I  have  succeeded  in 
reducing  the  dislocation  at  once,  by  putting  up  the  limb  very  tightly  in 
wooden  splints,  so  as  to  give  a  degree  of  solidity  to  it,  and  to  permit 
the  lever-like  movement  of  the  shaft  of  the  bone  to  be  employed  ;  and 
then,  putting  the  patient  under  chloroform,  I  have  replaced  the  bone 
without  much  difficulty.  Should  the  surgeon  have  omitted  to  reduce 
the  dislocation  in  the  first  instance,  he  must  wait  until  the  fracture  has 
become  firmly  united,  and  then,  putting  the  limb  in  splints  or  in  starch, 
he  may  try  to  effect  reduction,  which,  however,  wdll  then  be  very 
difficult. 

The  fracture  in  a  limb  which  is  the  seat  of  an  old  Unreduced  Dislocation 
is  necessarily  of  very  rare  occurrence,  but  occasions  no  serious  difficulty 
in  diagnosis  or  treatment.  I  once  saw  and  treated  successfully  with 
Dr.  Bryant  a  case  of  this  kind  in  the  person  of  an  old  gentleman  who, 
falling  on  the  ice,  fractured  the  left  humerus,  which  had  been  the  seat  of 
an  unreduced  dislocation  forwards  for  more  than  fifty  years. 

The  existence  of  an  Ankylosed  Joint  in  a  fractured  limb  gives  but 
little  trouble,  beyond  the  necessit}''  of  modifying  the  splints  in  such  a 
way  as  to  fit  the  shape  of  the  limb.  I  have  treated  fractures  of  the 
thigh,  leg,  and  arm  in  such  circumstances  with  perfect  success,  by 
adapting  the  splints  to  the  angle  formed  by  the  stiffened  joint. 

Fracture  of  a  bone  into  the  Site  of  an  Excised  Jomt  presents  no  pecu¬ 
liarity  of  importance.  I  have  met  with  it  in  the  humerus  at  the  elbow, 
and  have  treated  the  case  as  one  of  ordinary  fracture  of  the  epiphysis. 

Fracture  of  the  bone  in  the  Stump  of  an  Amjmtated  Limb  is  a  rare 
accident.  I  have  twice  had  such  cases  under  my  care ;  once  in  a  man, 
and  another  time  in  a  woman,  each  of  whom  fractured  the  femur  low 
down  in  a  limb  which  had  been  amputated  below  the  knee.  There  was 
no  displacement  of  the  fractured  bone  in  either  case,  showing  the  influ¬ 
ence  of  the  weight  of  the  limb  in  addition  to  muscular  contraction  in 
occasioning  displacement  of  the  lower  fractured  fragment.  In  each  case 
the  accident  was  the  consequence  of  a  fall,  and  union  readily  took  place 
under  the  starched  bandgage. 

In  cases  of  simple  fracture  occurring  in  the  neighborhood  of,  or  impli¬ 
cating  large  joints,  2:>assive  motion  is  very  common!}"  recommended  at 
the  end  of  from  four  to  six  weeks ;  I  think,  however,  with  Tincent,  that 
this  is  often  apt  to  do  more  harm  than  good,  and  is  seldom  required, 
the  natural  action  of  the  muscles  of  the  part  being  fully  sufficient  to 
restore  the  movements  of  the  articulation,  which  may  be  assisted  by 
friction  and  douches. 

Amputation  is  but  very  seldom  required  in  simple  fractures,  and  I  have 
never  had  occasion  to  practise  it.  Yet,  in  cases  of  very  extensive  and 
severe  comminuted  simifie  fracture  of  the  lower  end  of  the  femur,  or  of 
the  upper  part  of  the  bones  of  the  leg,  w"ith  imiDlication  of  the  knee-joint 
and  injury  to  the  popliteal  or  tibial  arteries,  as  indicated  by  the  cessation 
of  pulsation  in  the  vessels  of  the  foot,  removal  of  the  limb  might  be 


COMPOUND  FRACTURE. 


825 


proper,  in  order  to  save  the  patient  from  gangrene  or  diffused  traumatic 
aneurism.  But  it  is  only  when  the  main  artery  has  been  injured  by 
spicula  of  fractured  bone,  that  such  fractures  will  require  amputation. 
I  have  had  under  my  care  a  man,  in  whom  the  condyles  of  both  femora 
and  the  left  patella  were  crushed  into  numerous  pieces  by  a  fall  from  a 
great  height  on  both  knees,  the  limbs  feeling  like  bags  of  loose  fragments 
of  bone  at  the  seat  of  the  injury;  yet,  as  neither  the  skin  was  broken 
nor  the  vessels  injured,  though  both  the  knee-joints  appeared  to  be 
disorganized,  the  limbs  were  preserved,  and  good  union  ensued. 

Compound  Fracture. — A  compound  fracture  is  that  form  of  injury 
in  which  there  is  an  open  wound  leading  down  to  the  broken  bone,  at 
the  seat  of  fracture.  This  injury  is  not  only  far  more  tedious  in  its  cure 
than  simple  fracture,  but  infinitely  more  dangerous.  The  tediousness 
depends  upon  the  communication  of  the  fracture  with  the  external  air, 
causing  it  to  unite  by  a  slow  process  of  granulation,  instead  of  by  the 
more  speedy  adhesive  action  that  occurs  in  the  simple  form  of  injury. 
The  danger  is  likewise  partly  due  to  the  same  cause;  the  process  of 
granulation  and  suppuration  being  often  attended  b}’’  profuse  discharge 
of  pus  from  abscesses,  by  long-continued  exfoliation  of  bone,  or  by  the 
supervention  of  secondary  disease,  such  as  hectic,  phlebitis,  pneumonia, 
or  eiysipelas,  so  as  to  lead  to  the  eventual  loss  of  limb  or  life.  Besides 
these  dangers,  which  may  be  looked  upon  as  indirect,  the  violence  that 
occasions  a  compound  fracture  often  shatters  the  limb  to  such  an  extent, 
as  to  lead  to  the  immediate  supervention  of  traumatic  gangrene,  to  the 
loss  of  life  by  hemorrhage,  or  to  the  certain  and  speedy  disorganization 
of  the  limb,  as  the  consequence  of  the  reactionary  inflammation. 

Question  of  Amputatioii. — As,  therefore,  compound  fracture  is  attended 
not  only  by  great  prospective  dangers,  but  also  by  serious  immediate  risk, 
the  first  question  that  always  presents  itself  in  a  case  of  this  injury  is, 
whether  the  limb  should  be  removed,  or  an  attempt  be  made  to  save  it. 
It  is  of  great  importance  to  settle  this  point  at  once;  for,  if  amputation 
be  determined  upon,  it  should  be  done  with  as  little  delay  as  possible, 
there  being  no  period  in  the  progress  of  the  case  so  favorable  for  opera¬ 
tion  as  the  first  four-and-twenty  hours.  Should  an  injudicious  attempt 
have  been  made  at  saving  the  limb,  the  Surgeon  must  wait  until  suppu¬ 
rative  action  has  been  set  up  before  he  can  remove  it ;  and  then  he  will 
very  commonly  find  that  the  occurrence  of  some  of  the  diffuse  inflamma¬ 
tory  affections  of  an  erysipelatous  character  will  render  any  operation 
impracticable ;  or  the  supervention  of  traumatic  gangrene  may  compel 
him  to  amputate  in  the  most  unfavorable  circumstances.  At  a  late 
period  in  the  progress  of  the  case,  amputation  may  be  required,  in  order 
to  rid  the  patient  of  a  necrosed  and  suppurating  limb  that  is  exhausting 
him  by  hectic. 

It  is  true  that  primaiy  amputations  are  very  commonly  fatal,  especially 
when  practised  near  the  trunk;  yet  this  cannot  with  justice  be  urged  as 
an  argument  against  their  performance,  as  recourse  should  never  be  had 
to  primary  amputation  except  in  cases  in  which  it  is  evident  that  the 
patient’s  life  must  in  all  probability  be  sacrificed  by  the  unsuccessful 
attempt  to  save  the  limb.  In  determining  the  cases  in  which  immediate 
amputation  should  be  performed,  no  very  definite  rules  can  be  laid  down, 
and  much  must  at  last  be  left  to  the  individual  judgment  and  experience 
of  the  Surgeon.  One  will  attempt  to  save  a  limb  which  another  condemns. 
But,  in  coming  to  a  conclusion  upon  this  important  question,  he  must  bear 
in  mind  that, though  it  is  imperative  to  do  everything  in  his  power  to  save 
a  limb,  yet  the  preservation  of  a  patient’s  life  is  the  main  point,  and  that 


826 


FRACTURES. 


course  is  the  proper  one  which  offers  the  greatest  prospect  of  effecting  this. 
A  wise  conservatism  is  much  to  be  applauded,  but  decision  in  determining 
the  expediency  of  amputation  is  equally  the  characteristic  of  a  good  Sur¬ 
geon.  In  coming  to  a  conclusion  on  a  question  of  such  vital  moment  as 
this,  he  must  consider,  not  only  the  nature  and  extent  of  the  fracture,  but 
the  age,  constitution,  and  habits  of  the  patient;  and  though  he  may  be 
guided  by  those  general  rules  which  have  already  been  laid  down  at  pp. 
181  and  199,  when  treating  of  amputation  in  contused  wounds  and  in  gun¬ 
shot  injuries,  yet  he  will  often  show  more  wisdom  and  the  greatest  amount 
of  skill,  in  departing  from  the  strict  letter  of  surgical  law,  and  in  making 
a  successful  effort  to  save  a  limb,  which,  by  adherence  to  surgical  precepts 
would  be  condemned  ;  or  in  attempting  to  preserve  the  patient’s  life,  by 
sacrificing  a  limb  that  is  not  injured  to  a  degree  that  would  usually  be 
considered  to  justify  amputation. 

1.  Those  fractures  must  be  looked  upon  as  most  unfavorable  in  which 
the  wound  is  the  consequence  of  the  violence  that  breaks  the  bone,  and 
in  which  there  is  much  Laceration  of,  and  Extravasation  into,  the  Soft 
Parts  ;  more  particularly  if  the  integuments  be  stripped  off,  portions  of 
the  muscular  bellies  protrude,  and  the  planes  of  areolar  tissue  between 
the  great  muscles  of  the  limb  be  torn  up  and  infiltrated  with  blood. 
Injuries  of  this  description  occurring  in  the  lower  extremity  always 
require  amputation.  The  danger  to  the  patient  increases  not  only  in  pro¬ 
portion  to  the  amount  of  comminution  of  the  bones  and  of  injury  to  the 
soft  parts,  but  almost  in  the  exact  ratio  of  the  proximity  of  the  injury 
to  the  trunk.  Thus,  amputation  of  the  thigh  for  bad  compound  fracture 
of  the  leg,  though  a  very  serious  operation,  is  sufficiently  successful ; 
but  when  the  femur  itself  is  badly  fractured  and  amputation  of  the  thigh 
high  up  is  required,  recovery  can  indeed  but  seldom  be  expected.  A  bad 
compound  fracture  of  the  thigh,  high  up,  ma}’’  almost  be  looked  upon  as 
a  fatal  accident  {vide  pp.  57  and  202).  In  the  arm,  such  accidents  are 
not  so  serious,  and  the  member  may  be  saved,  unless  the  bones  be  greatly 
comminuted. 

2.  The  complication  of  a  compound  fracture  with  the  Wound  of  a 
Large  Joint,  more  especiall}"  if  there  be  crushing  or  splintering  of  the 
bones  which  enter  into  its  formation,  with  extensive  laceration  of  the 
soft  parts,  is  one  of  the  most  serious  injuries  that  can  be  inflicted  on  a 
limb;  and,  when  occurring  in  the  lower  extremity,  it  may  be  looked  upon 
as  a  case  for  amputaticn — unless  it  be  the  hip-joint  that  is  damaged,  when 
there  will  generally  be  so  much  injury  of  the  pelvic  bones  and  their  con¬ 
tained  viscera,  as  to  preclude  the  performance  of  any  operation.  When 
the  elbow  or  the  shoulder-joint  is  the  seat  of  compound  comminuted  frac¬ 
ture,  with  extensive  injury  of  the  soft  parts,  and  possibly  laceration  of 
contiguous  nerves  or  large  bloodvessels,  the  case  is  one  for  immediate 
amputation.  But,  if  the  injury  be  limited  to  the  bones,  the  soft  parts 
being  in  a  favorable  state,  resection  of  the  articulation  may  advanta¬ 
geously  be  practised.  This  operation  is  usually  a  somewhat  irregular 
proceeding,  being  conducted  according  to  the  extent  of  the  wound,  and 
consisting  rather  in  picking  out  the  shattered  fragments  of  bones,  and 
sawing  off  projecting  and  sharp-pointed  fragments,  than  in  methodical 
excision. 

A  peculiar  accident  is  occasionally  met  with  in  young  people,  consist¬ 
ing  in  a  fracture  of  one  of  the  long  bones  at  the  junction  of  the  shaft  and 
epiphysis,  and  the  protrusion  of  the  end  of  the  shaft  through  the  muscles 
and  integuments.  In  these  cases,  although  the  fracture  is  in  close  vicinity 
to  the  joint,  the  articulation  is  not  affected,  and  careful  examination  will 


COMPLICATIONS  OF  COMPOUND  FRACTURE. 


327 


always  prove  its  sound  condition.  Reduction  in  such  cases  is  difficult, 
and  is  usually  impossible  to  maintain  without  sawing  off  the  projecting 
end  of  the  shaft.  This  is  easily  done,  and  union  takes  place  readily 
between  the  epiphysis  and  the  remainder  of  the  shaft.  In  two  instances 
in  which  I  have  had  to  do  this  in  lads,  one  near  the  shoulder,  the  other 
near  the  ankle,  an  excellent  result  without  impairment  of  freedom  of  action 
in  the  joint  followed  the  operation. 

3.  When  one  of  the  larger  Arteries  of  the  Limb  has  been  xcounded  by 
the  violence  that  occasions  the  fracture,  or  has  been  lacerated  by  the 
broken  bone  itself,  there  ma}'  be  copious  arterial  hemorrhage  externall}’’, 
as  well  as  extravasation  into  the  general  areolar  tissue  of  the  limb. 
These  cases  most  commonly  require  immediate  amputation.  Whilst  the 
patient  is  being  examined,  and  preparations  made  for  the  operation, 
dangerous  effusion  of  blood  must  be  carefully  prevented  by  the  elevated 
position  and  by  the  application  of  a  tourniquet.  For  want  of  this  simple 
precaution,  I  have  seen  very  large  and  even  fatal  quantities  of  blood 
gradually  lost,  by  being  allowed  slowly  to  trickle  from  the  wound. 

In  these  cases  it  has  been  proposed,  b}^  some  Surgeons  of  great  emi¬ 
nence,  to  enlarge  the  wound  in  the  limb,  or  to  make  an  incision  down  to 
the  fracture,  and  attempt  to  tie  the  artery  where  it  has  been  injured. 
It  is  eas3"  to  give,  but  difficult  to  carry  out,  such  precepts.  In  most 
cases  they  are  scarcel^^  practicable,  as  the  Surgeon  would  have  to  grope 
in  the  midst  of  bleeding  and  infiltrated  tissues,  and  would  experience  the 
greatest  possible  difficult^"  in  finding  the  wounded  vessel,  after  a  search 
which  would  materially  tend  to  increase  the  disorganization  of  the  limb. 
Even  after  the  removal  of  a  limb  in  this  condition,  it  is  often  by  no  means 
easy  to  find  the  artery  that  has  poured  out  blood ;  and  how  much  more 
difficult  must  it  not  be  to  search  for  it  successfully  during  life? 

The  ligature  of  the  artery  at  a  higher  point  of  the  limb  does  not  hold 
out  much  prospect  of  success,  for  the  same  reasons  that  render  its  employ¬ 
ment  inadmissible  in  ordinaiy  wounds  of  arteries  (p.  244).  If,  then, 
proper  means  directed  to  the  'wound,  such  as  position,  pressure,  or  perhaps 
the  attempt  at  ligature  if  the  arteiy  can  be  easily  reached,  be  not  suc¬ 
cessful,  no  course  is  left  to  the  Surgeon  but  to  amputate  the  limb  without 
delay.  This  is  more  especiall}’  the  case  if  it  be  the  lower  extremity  that 
is  injured;  in  the  arm,  there  is  a  better  prospect  of  our  being  able  to 
arrest  the  bleeding  without  having  recourse  to  this  extreme  measure. 

4.  Comminution  or  Splintering  of  the  Broken  Bone  is  always  a  serious 
complication  of  a  compound  fracture.  Here  the  case  is  very  different 
from  what  occurs  in  similar  circumstances  in  a  simple  fracture.  Exten¬ 
sive  suppuration  will  set  in  ;  the  splinters,  if  completely  or  nearly 
detached,  will  lose  their  vitality,  and  not  only  produce  all  the  irritation 
that  would  result  from  the  inclusion  of  rough  and  pointed  foreign  bodies 
in  the  interior  of  a  limb,  but,  if  numerous,  will,  on  their  removal  or  sepa¬ 
ration,  leave  the  member  shortened  and  permanently  deformed.  The 
treatment  of  such  cases  will  depend  on  the  seat  of  the  injuiy,  and  the 
extent  of  the  comminution.  Compound  and  comminuted  fractures  of  the 
femur  ma}",  except  when  occurring  in  the  upper  third,  generall}^  be 
looked  upon  as  cases  for  immediate  amputation  {vide  p.  200) ;  the  only 
other  exceptions  being  when  the  comminution  is  trivial,  the  splinters 
large,  l3’ing  in  the  axis  of  the  bone,  and  the  subject  3’oung.  In  the  arm, 
forearm,  and  hand,  and  in  the  leg,  provided  the  knee  and  ankle-joints 
be  not  involved,  much  ma3^  be  done  in  the  wa3^  of  removing  splinters  of 
detached  bone,  and  sawing  off  smoothly  the  rugged  ends  of  the  fixed 
fragments.  The  larger  attached  and  “  secondaiy”  should  be  left,  as  the3^ 


828 


FRACTURES. 


will  throw  out  callus,  and  become  buttresses  of  support  to  the  broken 
bone.  If  a  considerable  quantity  of  splintered  bone  have  been  extracted 
from  a  limb,  care  must  be  taken  that  in  putting  up  the  fracture  too 
complete  extension  is  not  maintained,  lest  a  gap  be  left,  which  cannot 
be  filled  up  by  new  bone,  and  a  weakened  limb  result.  It  is  better  to 
place  the  bones  in  proper  apposition,  and  to  let  the  patient  recover  with 
a  shortened  but  strong  and  otherwise  useful  limb. 

5.  The  complication  of  a  had  Comjyound  Fracture  requiring  Amputa¬ 
tion  low  doivn  in  a  Limb^  ivith  a  Simple  Fracture  high  up^  is  a  serious 
one.  The  question  that  will  here  arise  is :  Should  the  amputation  be 
performed  above  the  compound  and  below  the  simple  fracture,  or  above 
both?  The  answer  to  this  must  depend  on  the  condition  of  the  limb 
between  the  fractures.  Suppose  that  there  be  a  badl}^  comminuted  and 
compound  fracture  of  the  lower  third  of  the  leg,  with  a  simple  fracture 
of  the  middle  of  the  thigh ;  or  a  crash  of  the  hand  or  forearm,  with 
simple  fracture  of  the  middle  of  the  humerus ;  how  should  the  Surgeon 
act  ?  It  appears  to  me  that  the  proper  course  to  adopt  in  such  a  case 
as  this,  would  mainly  depend  on  the  conditions  of  the  intervening  soft 
parts.  If  these  be  sound,  free  from  extravasation,  not  contused  or 
lacerated,  the  limb  may  with  safety  be  removed  just  above  the  lower 
fracture,  the  upper  fracture  being  treated  on  ordinary  principles.  But 
if  there  be  extensive  bruising  of  the  limb  with  ecchj’mosis  or  deep  ex¬ 
travasation  between  the  fractures,  then  it  would  clearly  be  useless  to 
amputate  low  down,  as  not  only  would  the  stump  have  to  be  formed  of 
tissues  in  a  state  of  disorganization,  but  the  infiammation  set  up  at  the 
seat  of  operation  would  speedil}'  spread  into  the  structures  filled  by 
extravasation,  and,  setting  up  unhealth}^  suppuration  in  these,  would 
spread  upwards  to  the  higher  fracture,  converting  it  into  a  compound 
one  of  the  worst  kind.  In  such  cases,  therefore,  where  there  is  extensive 
disorganization  of  the  intervening  soft  parts,  it  appears  to  me  that  the 
proper  course  for  the  Surgeon  to  pursue  is  to  remove  the  limb  at  or 
above  the  line  of  the  higher  fracture. 

6.  The  complication  of  a  Dislocation  high  up  ivith  a  bad  Compound 
Fracture  low  down^  as  when  the  shoulder  is  dislocated,  and  the  hand  is 
crushed,  is  not  so  serious;  the  dislocation  having  been  reduced,  the  limb 
may  be  amputated  low  down  with  safety.  This  practice  I  had  occasion 
to  adopt  some  3’ears  since  in  a  3’oung  man  who  met  wdth  a  bad  crush  of 
the  hand  and  forearm,  with  dislocation  of  the  humerus  into  the  axilla, 
in  consequence  of  the  limb  having  become  entangled  in  machineiy.  If, 
however,  the  compound  fracture,  unattended  by  an3^  of  the  complications 
that  have  just  been  mentioned,  occur  in  a  3'oung  or  otherwise  healthy 
subject,  we  must,  of  course,  attempt  to  save  the  limb,  and  shall  general- 
13^  succeed  in  doing  so. 

Treatment  of  Compound  Fracture. — In  the  management  of  a  com¬ 
pound  fracture,  more  especiall3^  of  the  lower  extremity,  special  apparatus, 
such  as  ]MTnt3're’s,  Liston’s,  or  the  bracket-splints,  double  inclined  planes, 
swdng-boxes,  and  fracture-beds,  are  often  necessaiy,  in  order  to  obtain 
access  to  the  wound,  so  as  to  dress  it  properl3",  and  to  place  the  limb  in 
the  best  position  for  union.  In  many  cases  the  starched  or  plaster 
bandage  may  very  advantageously  be  used;  but  it  requires  caution, 
as  swelling  and  consequent  strangulation  of  the  limb  ma3’’  take  place 
under  it. 

There  are  several  points  that  require  special  attention.  These  are;  1, 
the  Reduction  and  the  Management  of  any  Protruding  Bone ;  2,  the 
Management  of  Splinters;  3,  the  Closure  of  the  Wound  ;  and  4,  the 


TREATMENT  OF  COMPOUND  FRACTURE. 


329 


Subduing  Consecutive  Inflammation.  It  is  in  carrying  out  these  indica¬ 
tions  that  the  whole  treatment  of  the  injuries  is  involved,  in  those  cases 
in  which  the  limb  admits  of  being  saved. 

The  Reduction  of  compound  fractures  must  be  accomplished  with  the 
same  attention  to  gentleness  as  in  that  of  simple  ones.  In  the  majority 
of  cases,  no  great  difficult}' is  experienced  ;  and  after  reduction,  the  limb 
should  be  placed  on  a  well  padded  splint,  properly  protected  in  the 
neighborhood  of  the  wound  with  oiled  silk,  so  as  to  prevent  soiling  to 
the  pads  by  blood  and  discharge.  In  some  cases,  however,  considerable 
difficulty  arises  in  the  reduction,  from  the  protrusion  of  one  of  the 
broken  fm^ments  which  has  been  driven  through  the  skin,  either  bv  care- 
less  handling  of  the  limb  in  carrying  the  patient,  or  else  by  the  muscular 
contractions  dragging  the  lower  fragment  forcibly  upwards,  and  thus 
causing  perforation  of  the  integument.  The  protruded  bone  must,  if 
possible,  be  gently  replaced,  by  relaxing  the  muscles  of  the  limb,  and 
thus  bringing  the  soft  parts  over  it.  Sometimes,  however,  it  is  so  tightly 
embraced  by  the  skin,  which  appears  to  be  doubled  in  underneath,  that 
enlargement  of  the  wound  becomes  necessary  before  it  can  be  replaced. 
In  other  cases,  again,  reduction  cannot  be  effected  or  maintained,  unless 
the  sharp  and  projecting  point  of  bone  be  sawn  off.  This  is  best  done 
with  an  ordinary  amputating  saw,  the  neighboring  soft  parts  being  pro¬ 
tected  with  a  split  card  ;  or  else  by  passing  the  blade  of  a  Butcher’s  saw 
under  the  bone  and  cutting  upwards.  The  limb,  as  I  have  found  in 
several  cases  in  which  it  has  been  necessary  to  have  recourse  to  this 
procedure,  is  not  ultimately  weakened  or  necessarily  shortened  by  it. 

After  the  reduction,  the  great  object  is,  if  possible,  to  convert  the 
compound  into  a  simple  fracture  by  the  closure  of  the  external  wound. 
Xo  pains  should  be  neglected  to  effect  this  desirable  end.  If  it  can  be 
accomplished,  the  tediousness  and  danger  of  the  case  are  greatly  lessen¬ 
ed;  the  patient  being  saved  from  the  whole  process  of  suppuration,  with 
all  its  attendant  evils.  But  the  chance  of  closing  the  wound  in  the  soft 
parts  will  vary  greatly  in  different  cases,  depending  chiefly  on  the  way 
in  which  it  has  been  produced,  whether  by  transfixion  of  the  skin  by  the 
sharp  angular  fragment,  or  by  the  direct  violence  which  has  occasioned 
the  fracture.  If  the  wound  be  small,  clean  cut,  and  occasioned  by  the 
protrusion  of  the  fragment  rather  than  by  the  direct  violence  which 
occasioned  the  fracture,  we  may  hope  to  succeed  in  our  object  by  follow¬ 
ing  Sir  A.  Cooper’s  recommendation  of  applying  it  to  a  piece  of  lint 
soaked  in  its  blood,  or,  what  is  better,  saturated  with  collodion,  and  thus 
obtaining  union  by  direct  adhesion.  The  dressing  should  be  left  undis¬ 
turbed  until  it  loosens  of  itself  at  the  end  of  a  week  or  two,  when  the 
wound  will  probably  be  found  to  be  closed.  With  the  double  object  of 
closing  the  wound  and  of  preventing  decomposition  of  its  fluids  by  the 
entrance  of  organisms  floating  in  the  air.  Lister  recommends  the  employ¬ 
ment  of  the  antiseptic  method  (p.  113),  from  which  good  results  have 
been  obtained.  If  the  wound  be  large  and  lacerated,  if  a  joint  have  been 
opened,  if  the  wound  have  been  inflicted  by  the  same  violence  that  has 
broken  the  bone,  or  if  there  be  much  bruising  of  tlie  edges  and  surround¬ 
ing  tissues,  with  extravasation  into  the  limb,  suppuration  must  neces¬ 
sarily  ensue,  and  thus  direct  union  cannot  be  expected  to  take  place. 
In  these  circumstances,  it  is  in  accordance  with  the  best  principles  of 
surgery,  not  to  follow  the  routine  practice  of  attempting  to  close  the 
wound,  which  cannot  possibly  unite  by  the  first  intention,  but  to  treat 
it  like  any  other  contused  wound,  and  apply  carbolized  water-dressing 
from  the  very  first,  so  as  to  allow  a  vent  for  the  discharges  that  will  take 


830 


FRACTURES. 


place  after  the  first  folir-ancl-twent^’-hours.  If  these  be  retained  in  the 
limb  by  the  external  wound  being  kept  closed  by  an}’  dressing,  whatever 
its  nature  may  be,  deep  infiltration  of  the  areolar  intermuscular  planes 
will  ensue,  with  much  local  tension  and  purulent  infiltration,  accompa¬ 
nied  by  severe  constitutional  irritation,  followed  probably  by  pysemia. 
It  is,  I  believe,  in  consequence  of  the  free  vent  thus  afforded  to  the  dis¬ 
charges,  and  of  their  retention  being  avoided,  that  many  of  the  worst 
looking  cases  of  compound  fracture — especially  of  the  leg — those  in 
which  there  has  been  extensive  sloughing  of  the  soft  parts  around  the 
wound,  with  exposure  of  the  fractured  fragments,  eventually  do  the  best. 
The  danger  in  such  cases  is  a  remote  one,  from  hectic  and  exhaustion ; 
not  an  immediate  and  grave  one,  from  erysipelas  and  purulent  absorp¬ 
tion,  or  septic  poisoning,  resulting  from  the  infiltration  of  the  limb. 

After  the  position  of  the  limb  and  the  management  of  the  external 
wound  have  been  attended  to,  an  endeavor  must  be  made  to  moderate 
the  local  inflammatory  action^  and  to  lessen  constitutional  irritation. 
This  is  best  effected  by  leaving  the  part  undisturbed  and  untouched  as 
long  as  possible.  The  great  art  in  the  successful  treatment  of  compound 
fractures  consists  in  not  disturbing  the  limb  or  meddling  with  the  wound. 
For  days  or  even  weeks  the  limb  may  sometimes  advantageously  be  left 
without  interference,  when  once  it  has  been  carefully  put  up.  Should, 
however,  much  swelling  have  taken  place,  and  the  wound  show  no  dispo¬ 
sition  to  heal  by  the  first  intention,  but  become  inflamed  and  sloughy, 
and  should  much  inflammatory  action  be  set  up  in  the  limb,  this  may  be 
moderated  by  irrigation  (Fig.  51),  and  by  the  application  of  cold  evapo¬ 
rating  lotions.  The  part  should  be  elevated  and  but  lightly  covered, 
the  bed-clothes  being  well  raised  by  means  of  a  cradle,  so  as  not  to  press 
on  the  limb,  and  to  allow  space  for  the  evaporation  of  the  cold  lotion ; 
care  being  taken,  at  the  same  time,  that  the  bandages  be  applied  very 
loosely,  merely  with  a  sufficient  degree  of  force  to  retain  the  limb  upon 
the  splint,  as  inflammatory  infiltration,  that  might  rapidly  induce  stran¬ 
gulation  of  the  part,  is  apt  to  ensue.  The  constitutional  irritation  must 
be  subdued  by  the  administration  of  opiates,  together  with  an  aperient, 
on  the  morning  following  the  accident :  and  these  medicines  must  be 
repeated  from  time  to  time  during  the  first  few  days.  Moderate  and 
cooling  regimen  must  be  employed,  and  the  patient  be  disturbed  as  little 
as  possible.  In  many  cases  suppuration  rapidly  sets  in,  and,  if  the 
patient  be  addicted  to  drinking,  the  constitutional  disturbance  soon 
assumes  the  irritative  form:  in  these  circumstances,  it  is  of  great 
moment  that  support,  and  even  stimulants,  be  freely  given  ;  they  must 
be  allowed  from  the  very  first,  and  increased  in  proportion  to  the  depres¬ 
sion  of  the  patient’s  strength,  or  as  symptoms  of  nervous  irritation 
come  on. 

If  there  be  much  extravasation  of  blood  into  and  bruising  of  the  soft 
parts,  great  tension  of  the  limb,  followed  by  unhealthy  suppuration  and 
slongliing,  will  take  place  in  the  neighborhood  of  the  wound  ;  free 
incisions  are  then  required  to  remove  the  tension  and  strangulation  of 
the  tissues,  and,  by  letting  out  the  broken-down  blood  and  pus,  to  lessen 
the  risk  of  the  occurrence  of  gangrene.  It  is  in  these  cases  that  much 
injury  results  from  blindly  following,  as  a  routine  practice  in  all  cases 
indiscriminately,  the  treatment  which  is  undoubtedly  of  the  highest 
value  in  some;  viz.,  that  of  keeping  over  the  w’ound  any  impervious 
dressing,  whether  antiseptic,  plasters,  or  a  pad  of  lint  that  has  become 
hard  and  impermeable  by  imbibition  of  dried  blood,  with  a  view  to 
closure  by  the  first  intention.  The  natural  vent  to  the  discharge  through 


TREATMENT  OF  COMPOUND  FRACTURE. 


831 


the  external  opening  being  interfered  with,  deep  infiltration  takes  place 
through  the  areolar  planes  of  the  limb,  and  the  most  extensive  local 
mischief  may  result,  p\^a3mia  being  almost  certain  to  ensue.  xVs  soon  as 
suppuration  is  fairl}^  established,  a  light  poultice  or  thick  oakum  water¬ 
dressing  should  be  applied,  and  the  burrowing  of  matter  prevented  by 
making  counter-openings  where  necessaiy,  by  the  application  of  a  com¬ 
press,  and  by  attention  to  the  position  of  the  limb.  The  fracture- 
apparatus  must  be  kept  scrupulousl}’-  clean,  especially  in  summer ;  the 
bandages  changed  as  often  as  soiled,  and  the  pads  well  protected  with 
oiled  silk.  During  this  period  various  complications,  such  as  erysipelas, 
inflammation  of  the  absorbents  and  veins,  and  low  forms  of  pneumonia, 
are  apt  to  occur,  requiring  special  consideration  and  treatment;  so  also, 
if  the  discharge  be  abundant,  hectic,  wdth  its  sweats  and  gastro-intestinal 
irritation,  may  come  on,  requiring  full  support  of  the  powers  of  the 
S3"stem,  and  the  administration  of  the  mineral  acids  and  other  remedies, 
according  to  circumstances.  As  the  confinement  to  bed  is  necessarily 
very  prolonged  in  these  cases,  often  extending  through  man^'  weeks  and 
months,  the  state  of  the  patient’s  back  should  be  attended  to,  and  he 
should  early  be  placed  upon  a  water-cushion,  or  h^^drostatic  bed,  lest 
sores  supervene.  As  the  wound  gradually  heals,  w’ater-dressing  must  be 
substituted  for  poultices,  so  as  not  to  sodden  the  parts  and  encourage 
suppuration,  and,  in  time,  the  red  or  blue  wash  for  the  water-dressing. 
The  bone  will  often  be  observed  Ij’ing  wdiite  and  bare,  bathed  in  pus,  at 
the  bottom  of  the  wound.  But  even  in  this  apparently  unfavorable  con¬ 
dition,  it  may  recover  itself:  its  vessels  gradually  depositing  l^unph  in 
points  on  its  surface,  and  this  l^miph  becoming  vascularized,  so  as  to 
cover  it  with  a  la^’er  of  florid  granulations  ;  in  other  cases,  necrosis  to  a 
greater  or  less  extent  will  take  place,  and  perfect  consolidation  does  not 
occur  until  the  bone  is  separated.  Curling  has  shown  that  those  portions 
of  necrosed  bone  are  slowest  in  detaching  themselves,  which  are  con¬ 
nected  with  the  lower  fragment.  In  some  instances  a  large  quantit^^  of 
provisional  callus  is  thrown  out,  in  which  the  necrosed  bone  is  implicated  ; 
and  then  the  process  of  separation  becomes  extremely  tedious  and  pro¬ 
tracted,  and  amputation  ma^’’  not  uncommonly'  become  necessaiy,  from 
the  powers  of  the  patient  being  unable  to  bear  up  in  so  prolonged  a 
struggle.  So  soon  as  some  consolidation  has  taken  place,  the  limb  should 
be  firmly  put  up  in  gutta-percha  or  leather  splints,  with  a  starched  ban¬ 
dage,  so  as  to  enable  the  patient  to  be  taken  put  of  bed,  to  change  the 
air  of  his  room,  and  thus  to  keep  up  his  general  health.  In  fitting  these 
splints,  care  must  be  taken  to  make  an  aperture  opposite  the  w'ound, 
through  which  it  may  be  dressed  (Fig.  123). 

Xeudbrfer  has  introduced  a  dry  plaster  of  Paris  dressing  for  compound 
fractures,  especially  those  produced  by^  gunshot,  and,  indeed,  all  attended 
by'  excessive  suppuration.  From  this  means  he  derived  the  best  possible 
results  in  the  German  wars  of  1864  and  1866.  His  method  is  as  follows. 
Beneath  the  seat  of  injury  he  places  eight  layers  of  linen  cloth,  and  on 
this  several  pounds  of  dry  gypsum  are  poured,  so  that  it  lies  under  and 
around  the  fracture,  until  there  is  a  wall  heaped  up  on  each  side  of  the 
wound,  wdiich  is  also  covered  in.  The  linen  cloths  are  then  brought  over 
like  a  many^-tailed  bandage,  and  the  whole  is  tied  up  by  short  lengths  of 
bandage.  As  the  plaster  becomes  impregnated  with  pus,  it  is  scraped 
off,  but  the  wound  is  on  no  account  to  be  meddled  with ;  new  plaster  is 
applied  where  the  old,  which  has  become  pasty',  has  been  removed. 
Neudorfer  states  that,  when  compound  fracture  has  been  treated  bv  the 
fixed  plaster  bandage,  this  should  be  generally  removed  at  the  end  of 


332 


FRACTUKES. 


fourteen  days.  After  this  the  dry  method,  as  above  described,  ma}'-  be 
applied,  and  no  splint  or  other  extemling  or  containing  apparatus  is 
required.  It  may  be  observed  that,  as  plaster  of  Paris  does  not  “set” 
with  albuminous  fluids,  it  is  not  hardened  by  the  pus,  but  merely  absorbs 
it,  becoming  past3\ 

The  time  required  for  the  proper  consolidation  of  a  compound  fracture 
varies  greatly,  according  to  the  amount  of  injuiydone  to  the  bones  and 
soft  parts,  and  the  age  and  constitution  of  the  patient.  In  the  most 
favorable  circumstances,  it  requires  double  or  treble  the  time  that  is 
necessary  for  the  union  of  a  simple  fracture.  Much  stiffiiess  of  the  limb 
from  rigidity  of  the  muscles  and  tendons  will  continue  for  a  considerable 
length  of  time  ;  this  ma}^  gradually  be  removed  by  frictions  and  douches. 

Secondary  Amputation  may  become  necessary  from  the  occurrence  of 
traumatic  gangrene,  and  then  it  must  be  done  in  accordance  with  the 
principles  alread}"  laid  down  when  speaking  of  that  operation  ;  but  more 
frequentl}’’  it  is  required  from  failure  of  the  powers  of  the  patient  in 
consequence  of  irritative  and  asthenic  fever,  induced  by-  general  disor¬ 
ganization  of  the  limb,  or  by  hectic  resulting  from  profuse  suppuration 
and  slow  necrosis  of  the  bones.  In  these  circumstances,  the  constitu¬ 
tion  suffers  from  the  local  irritation  which  is  the  source  of  the  wasting 
discharge ;  but,  by  removing  this  in  time,  and  seizing  an  interval  in 
which  constitutional  action  may  have  been  somewhat  lessened,  the 
patient’s  life  will  in  all  probability  be  preserved  ;  the  results  of  secondary 
amputation  for  compound  fracture  in  these  conditions  being  b}^  no  means 
unfavorable.  Indeed,  it  is  remarkable  to  see  how  speedil}^  the  constitu¬ 
tional  irritative  and  hectic  symptoms  subside  after  the  removal  of  the 
source  of  irritation  ;  the  patient  often  sleeping  well,  and  taking  his  food 
with  appetite  the  day  after  the  operation. 

The  proper  period  to  seize  for  the  performance  of  secondary  amputa¬ 
tion  in  the  earlier  stages  of  the  injuiy  is  often  a  most  critical  point.  As 
a  general  rule,  it  may  be  stated  that,  if  the  limb  be  not  removed  during 
the  first  twentj’-four  hours,  eight  or  ten  days  must  be  allowed  to  elapse 
before  the  operation  is  done  ;  as  during  that  time  constitutional  irrita¬ 
tion  and  suppurative  fever  are  too  general  and  active  to  render  fresh 
shock  to  the  system  admissible.  But  when  once  the  actions  appear  to 
tend  to  localize  themselves,  the  suppuration  becoming  more  abundant, 
the  redness  extending  but  slowl}^  and  the  constitutional  sj^mptoms  ’ 
merging  into  an  asthenic  form,  then  the  limb  may  be  removed  with  the 
best  prospect  of  success.  The  more  the  action  is  localized,  the  greater 
is  the  chance  of  the  operation  succeeding. 

In  many  cases  the  s^’mptomatic  and  suppurative  fever  so  rapidly 
becomes  asthenic,  that  the  Surgeon  must  seize  the  best  moment  he  can 
for  amputation.  In  these  circumstances  the  operation  is  seldom  very 
successful;  the  stump  becomes  sloughy,  eiysipelas  or  diffuse  inflamma¬ 
tion  of  the  areolar  tissue  comes  on,  or  s3"mptoms  of  p3’3emia  set  in,  and 
the  patient  speedil3''  dies.  In  other  cases  again,  between  the  stages  of 
the  inflammatory  and  suppurative  fever  and  the  supervention  of  the 
t3qohoid  S3unptoms,  there  is  a  marked  interval  of  twelve  or  twent3"-four 
hours,  or  even  more’.  During  this,  the  mischief  may  be  looked  upon  as 
in  a  great  measure  of  local  character ;  the  constitution  has  been  disturbed 
by  the  setting  up  of  the  inflammatoiy  action,  but,  this  having  terminated 
in  suppuration,  it  has  not  yet  become  seriously  depressed  by  the  con¬ 
tinued  irritation  of  the  discharge  from  the  injured  limb,  or  poisoned  by 
the  absorption  of  morbid  matters  from  it. 

The  patient’s  powers  must  not,  however,  be  allowed  to  sink  to  the  last 


BEXDIXG,  BREAKING,  AND  RESETTING  BONES.  833 


ebb  before  amputation  is  performed  ;  as  then,  if  the  shock  do  not  destroy 
life,  intercurrent  and  visceral  congestion,  or  some  low  form  of  inflamma- 
toiy  mischief,  will  not  improbably*  prove  fatal.  Much  as  “conservative” 
surgery  is  to  be  admired  and  cultivated,  and  hasty  or  unnecessary  ope¬ 
ration  to  be  deprecated,  I  cannot  but  think  that  the  life  of  the  patient  is 
occasionally  jeopardized,  and  even  lost,  by  disinclination  on  the  part  of 
the  Surgeon  to  operate  sufficiently  early  in  cases  of  compound  fracture, 
and  by  too  prolonged  attempts  at  saving  the  injured  limb. 

The  success  of  the  operation  will  in  a  great  measure  depend  upon  the 
after-treatment.  Large  quantities  of  stimulants  and  support  are  often 
required  in  London  practice  to  prevent  the  patient  from  sinking.  I 
have  frequently*  given,  with  the  best  results,  eight  or  ten  ounces  of  brandy*, 
twelve  or  sixteen  of  port  wine,  with  two  or  three.pints  of  porter,  in  the 
twenty*-four  hours  after  these  operations,  with  beef-tea,  arrow-root,  or 
meat,  if  the  patient  would  take  it,  and  have  found  it  absolutely  neces¬ 
sary*  to  do  so  to  obviate  death  from  exhaustion. 

At  a  later  period,  when  some  weeks  or  months  have  elapsed,  and  the 
fracture  has  not  united,  the  bones  are  necrosing,  and  the  patient  is  being 
worn  out  by*  hectic,  amputation  must  be  performed  at  any*  convenient 
moment,  and  is  often  done  with  great  success  if  it  be  not  deferred  till 
too  late;  for  here  the  mischief  is  entirely*  local,  and  the  constitution, 
suffering  only*  by*  the  debility  resulting  from  it,  quickly*  rallies  when  the 
cause  of  this  is  removed. 

Bending,  Breaking,  and  Resetting  Bones. — It  may*  happen,  that 
at  the  end  of  two  or  three  weeks  a  fractured  bone  is  found  in  a  position 
too  faulty*  to  be  remedied  by*  the  natural  process  just  described.  At  this 
period  the  bond  of  union  is  soft  and  yielding,  and  the  displacement,  if 
angular,  may  usually*  be  remedied  by*  frequent  re-adjustment  of  the  appa¬ 
ratus,  and  more  particularly*  by*  bandaging  the  fractured  fragments  in 
opposite  directions,  or  by*  the  use  of  pads  and  pressure  thus  exercised 
on  the  extremities  of  the  broken  bone.  If  this  period  be  allowed  to  pass 
by*,  and  the  fracture  be  allowed  to  become  consolidated,  it  may*  be  found 
to  be  so  badly  set  that  it  is  necessary*  to  forcibly*  bend  or  break  the  callus, 
in  order  to  improve  the  condition  of  the  limb.  When  the  displacement 
is  angular,  and  the  consolidation  not  very  firm,  as  is  usually*  the  case, 
this  may*  be  done  readily*  enough  ;  but  if  the  displacement  be  longitudi¬ 
nal,  and  much  time  have  elapsed  since  the  occurrence  of  the  injury*,  it 
will  be  difficult,  if  not  impossible,  to  remove  the  deformity*.  The  bending 
or  breaking  of  the  callus  is  best  done  under  the  infiuence  of  chloroform  : 
the  fracture  being  then  put  up  again,  speedy*  and  perfect  consolidation 
will  ensue.  In  this  way  I  have  several  times  remedied  a  faulty*  position 
in  fractured  bones,  although  from  six  to  ten  weeks  had  elapsed  from  the 
occurrence  of  the  injury*. 

A  bone  which  does  not  appear  to  have  been  very*  skilfully*  set,  and 
w*hich  presents  a  certain  amount  of  deformity*  when  the  splints  or 
apparatus  covering  it  are  removed,  may  gradually*  regain  its  proper  shape 
if  left  to  itself.  This  it  does  by  the  muscles  of  the  limb  mouldinor  the 
callus  whilst  still  somewhat  soft  and  yielding  into  a  proper  shape.  The 
callus  may*  be  quite  strong  enough  to  bear  the  weight  and  to  maintain 
the  length  of  the  limb  in  its  full  integrity*  after  the  removal  of  all  appa¬ 
ratus,  and  yet  be  sufficiently  yielding  to  become  slowly*  and  gradually* 
shaped  by*  the  action  of  the  muscles  of  the  limb  when  they*  are  left 
untrammelled  by  bandages. 

But  it  more  commonly*  happens  that  a  limb  which,  when  taken  out  of 
the  splints  at  the  proper  period,  then  appears  to  be  straight  and  of  good 


834 


FKACTURES. 


length,  gradually  yields  under  the  weight  of  the  body  and  the  strain  of 
the  muscles  ;  so  that,  at  the  end  of  a  few  weeks,  great  and  most  unsightly 
deformity  has  occurred.  In  these  cases  the  Surgeon  is  often  unduly 
blamed ;  and  to  his  unskilfulness  is  attributed  that  displacement  which, 
in  reality,  is  due  to  the  faulty  character  of  the  callus.  It  must  be  re¬ 
membered  that  there  is  every  degree  of  variety  in  the  firmness  of  callus, 
from  that  which  is  of  normal  consistence  to  that  which  is  quite  unable 
to  support  the  weight  of  the  limb  or  body,  and  that  yields  more  or  less 
quickl3^  under  the  pressure  to  which  it  is  subjected. 

Delayed  Union. — Occasional!}",  more  particularly  in  cases  of  frac¬ 
ture  of  the  femur,  tibia,  and  humerus,  the  union  between  the  broken 
fragments  is  delayed  several  w-eeks  beyond  the  usual  period  of  perfect 
consolidation.  This  anises,  in  the  majority  of  cases,  from  constitutional 
debility,  rather  than  from  local  causes.  When  it  is  found  at  the  expira¬ 
tion  of  six  or  eight  weeks  after  the  occurrence  of  simple  fracture  that 
the  callous  is  still  yielding,  the  general  health  should  be  improved  by 
tonics,  change  of  air,  etc.,  and  the  limb  securely  put  up  in  starched  or 
plaster  of  Paris  bandages.  Indeed,  I  believe  that  delayed  union  is  much 
less  likely  to  occur  in  patients  who  have  from  the  first  been  treated  by 
the  starched  bandage,  and  allowed  to  move  about,  than  in  those  who 
have  been  confined  to  bed  or  rather  to  the  house  in  the  ordinary  way. 

Ununited  Fractures  and  False  Joints. — Some  bones,  when 
broken,  very  rarely  unite  by  callus  or  plastic  matter,  their  fragments 
merely  being  kept  firm  by  the  intervention  of  the  aponeurotic  structures 
of  the  part,  as  is  the  case  with  the  patella.  This,  which  is  owing  to  a 
want  of  apposition  of  the  fragments,  and  is  dependent  on  the  condition 
of  the  part,  cannot  be  considered  a  diseased  action. 

It  occasionally  happens,  however,  in  fractures  of  the  shafts  or  of  the 
articular  ends  of  long  bones,  that  proper  union  does  not  take  place. 
This  may  be  owing  to  one  of  three  circumstances.  1.  No  uniting 
material  of  a  stronger  kind  than  a  loose  fibro-cellular  tissue  has  been 
formed;  2.  The  plastic  matter  that  has  been  thrown  out  has  only  devel¬ 
oped  into  fibrous  tissue,  not  having  undergone  osseous  transformation ; 
or,  3,  True  bony  union  has  taken  place,  but,  owing  to  some  peculiar 
state  of  the  patient’s  health,  the  callus  has  become  absorbed,  and  the 
fracture  loosened. 

In  the  first  and  third  conditions  we  have  an  Ununited  Fracture;  the 
ends  of  the  bone,  which  are  rounded  and  eburnated,  being  merely  con¬ 
nected  by,  and  enveloped  in,  a  loose  fibro-cellular  tissue. 

In  the  second  condition  we  have  a  Fa, he  Joints  the  ends  of  the  bone 
being  tied  together  by  strong  fibrous  bands.  The  structure  of  these 
false  joints,  which  has  beei^u  carefully  studied  by  Rokitansky,  presents 
two  distinct  varieties.  In  the  first,  which  partakes  of  the  character  of 
a  hinge-joint,  we  find  that  the  ends  of  the  fracture  are  smoothed  and 
rounded,  invested  with  a  dense  fibrous  periosteum,  and  united  to  one 
another  by  thick  bands  of  ligamentous  tissue,  in  such  a  way  as  usually 
to  admit  of  considerable  lateral  movement,  though  sometimes  they  are 
tolerably  firm.  In  the  other  variety  the  joint  partakes  of  the  ball-and- 
socket  character,  usually  to  a  very  imperfect  degree,  but  sometimes  in  a 
sufficiently  well  developed  manner,  one  end  of  the  bone  being  rounded 
and  invested  by  a  periosteum,  the  other  cup-shaped,  and  covered  by  firm 
smooth  fibroid  tissue.  The  bones  are  united  by  a  kind  of  capsule,  in- 
which  a  synovial-like  fluid  has  occasionally  been  found. 

The  form  that  the  false  joint  will  assume  depends  on  the  action  of  the 
muscles  which  influence  it.  Thus,  when  occurring  in  the  shafts  of  long 


UNUNITED  FKACTUEES  AND  FALSE  JOINTS. 


835 


bones,  where  it  is  subjected  to  movements  of  flexion  and  extension,  it 
will  assume  the  hinge-form ;  whilst,  when  it  is  seated  in  the  articular 
ends,  where  it  is  more  subjected  to  movements  of  rotation,  it  will  affect 
the  ball-and-socket  character. 

Non-union  of  fracture,  whether  resulting  in  false  joint  or  in  ordinary 
un united  fracture,  is,  undoubtedly,  very  rare.  I  have  very  seldom  met 
with  it  in  my  own  practice.  The  cases  that  have  been  under  m}^  care  at 
University  College  Hospital  have  almost  all  been  sent  up  from  various 
parts  of  the  country,  and  probably  present  but  a  very  small  proportion 
of  the  fractures  that  have  occurred  in  the  districts  from  which  thej'  have 
been  sent.  We  probably  exaggerate  the  frequency  of  non-union,  if  w^e 
say  that  it  occurs  in  the  proportion  of  one  in  a  thousand  cases  of  frac¬ 
ture  of  the  limbs. 

Causes. — The  causes  of  ununited  fracture  and  of  false  joint  are  con- 
stitutional  and  local. 

In  some  cases  the  Constitutional  Cause  appears  to  be  a  cachectic  state 
of  the  s^'stem  occurring  from  some  debilitating  disease,  such  as  fever, 
phthisis,  scurvy,  or  cancer,  or  from  any  depressing  influence,  in  conse¬ 
quence  of  which  there  is  not  sufficient  reparative  power  for  the  produc¬ 
tion  or  proper  development  of  the  plastic  matter,  by  which  the  fracture 
should  be  united.  If  this  have  been  deposited,  it  may,  under  the  influ-, 
ence  of  these  constitutional  causes,  again  become  absorbed,  and  the 
fractures  may  thus  be  loosened.  In  such  cases,  on  the  restoration  of 
the  health,  union  will  generally  take  place.  In  many  cases  no  constitu¬ 
tional  cause  for  the  want  of  union  can  be  detected,  the  patient  being  in 
excellent  health,  strong,  and  robust.  In  spontaneous  fractures,  union 
seldom  takes  place  very  readily  or  perfectl}'. 

Pregnancy  is  said  to  have  a  tendency  to  interfere  with  the  proper 
union  of  a  fracture;  this,  however,  I  consider  doubtful,  as  I  have  had 
under  my  care,  and  have  seen,  a  considerable  number  of  cases  of  frac¬ 
ture  in  pregnant  women,  which  united  in  the  ordinary  time.  Billroth 
has  made  a  similar  observation. 

Age. — Failure  of  union  in  fractures  is  very  rare  in  children,  and  when 
it  occurs  in  them  is  seldom  remedial,  unless  it  be  the  result  of  neglect 
or  of  improper  mechanical  treatment.  It  is  more  common  at  the  earlier 
adult  and  middle  ages.  Union  will  readily  occur  in  aged  individuals. 
Indeed,  advanced  age  appears  to  exercise  no  adverse  influence  on  the 
repair  of  fractures.  I  have  on  two  occasions,  in  my  own  practice,  known 
very  firm  and  perfect  consolidation  of  fracture  of  the  shaft  of  the  femur 
to  take  place  in  women  of  ninety  years  of  age  and  upwards. 

The  Local  Causes  are  various  and  important.  The  anatomical  con¬ 
dition  of  the  fragments,  as  regards  their  vascular  suj^ply,  is  perhaps 
that  on  which  want  of  union  is  most  immediately  dependent.  For  pro¬ 
per  union  to  take  place,  it  is  necessary  that  the  callus  be  deposited  from 
both  sides  of  the  fracture.  If  one  fragment  be  so  situated  that  suffi¬ 
cient  blood  is  not  sent  to  it  for  this  purpose,  not  only  may  want  of  union, 
but  necrosis  occur.  This  is  exemplified  in  fractures  of  the  superior 
articular  ends  of  the  humerus  and  femur.  In  intra-capsular  fracture  of 
the  anatomical  neck  of  the  humerus,  the  globular  head,  being  detached 
from  all  its  vascular  connections,  may  necrose.  In  intra-capsular  frac¬ 
ture  of  the  neck  of  the  femur,  the  head  of  the  bone,  still  retaining  some 
vascular  connection  through  the  medium  of  the  ligamentum  teres,  has 
sufficient  blood  furnished  to  it  to  prevent  its  death,  but  not  enough  to 
■form  eallus — hence  fibrous  union  takes  place.  In  the  shafts  of  the  long 
bones,  the  degree  of  union  will  be  dependent  in  a  great  measure  on  the 


336 


FRACTURES. 


conditions  of  the  vascular  supply  to  the  fragments,  through  the  medium 
of  the  nutritious  artery.  The  influsnce  of  the  rupture  of  the  nutritious 
arteiy  of  the  bone  by  the  line  of  fracture  running  across  it,  and  thus 
interfering  with  the  vascular  supply  of  one  of  the  fragments,  has  been 
investigated  by  Gueretin;  and  the  occasional  occurrence  of  atrophy  of 
the  bone  after  fracture,  has  been  shown  by  Curling  to  be  dependent 
upon  the  interruption  of  the  supply  of  arterial  blood  through  this  vessel. 
He  states  that  the  portion  of  bone  below  the  entrance  of  the  nutritious 
artery,  or  on  that  side  of  the  foramen  towards  which  the  blood  flows, 
being  deprived  of  its  proper  vascular  supply,  undergoes  certain  changes ; 
the  medullary  canal  becoming  expanded  and  the  osseous  tissue  less 
dense.  Gueretin  has  collected  cases  that  tend  to  prove  the  direct  con¬ 
nection  between  the  occurrence  of  ununited  fracture,  and  the  want  of 
2)roper  arterial  supply  to  one  of  the  fragments.  Thus,  in  the  humerus, 
the  course  of  the  nutritious  artery  is  from  above  downwards;  and  of 
thirteen  cases  of  ununited  fracture,  nine  were  found  to  be  situated  above 
the  canal  in  which  the  vessel  is  lodged.  In  the  forearm,  where  the  nu¬ 
tritious  artery  passes  from  below  upwards,  of  eight  cases  of  ununited 
fracture,  seven  occurred  below  this  vessel,  and  only  one  above.  Adams 
has,  however,  shown  tliat  the  number  and  size,  as  well  as  position,  of 
the  nutrient  arteries,  vary  considerably ;  and  hence  the  objection  that 
non-union  may  occur  in  a  fracture  of  any  part  of  the  shaft  of  a  long 
bone,  whereas  the  nutritious  artery  is  only  found  at  one  spot,  can  scarce- 

be  considered  a  very  valid  one. 

Some  bones  are  much  more  liable  than  others  to  disunion  of  their 
fractures.  According  to  the  statistics  collected  by  Norris,  it  would 
appear  that  the  femur,  the  humerus,  tlie  bones  of  the  leg,  and^  of  the 
forearm,  and  lastly  the  lower  jaw,  are  those  in  which  ununited  fractures 
most  frequently  occur,  and  that  in  the  order  which  has  been  given. 
Hamilton  states  that  in  his  experience  the  humerus  is  more  commonly 
the  seat  of  an  ununited  fracture  than  the  femur;  and  my  experience 
agrees  with  his. 

The  occurrence  of  ununited  fracture  is  occasionally  attributed  to  the 
mobility  or  want  of  proper  opposition  of  the  fragments  which  are  so 
situated  that,  instead  of  the  broken  surfaces  being  in  contact,  rotation 
of  the  limb  lias  caused  the  outer  and  periosteal  aspects  to  touch.  Doubt¬ 
less,  in  some  cases,  it  may  be  so  occasioned :  but  I  believe  that  these 
causes  are  not  nearly  so  frequent  in  their  operation  as  the  constitutional 
and  local  conditions  that  have  already  been  pointed  out.  The  interpo¬ 
sition  of  a  pieee  of  muscle  between  the  fragments  may  prevent  union. 
Of  this  I  saw  an  interesting  instance  some  years  ago,  in  which  want  of 
union  in  a  fractured  femur  was  owing  to  the  perforation  of  the  vastus 
muscle  by  the  upper  fragment,  and  its  entanglement  between  the  broken 
ends.  But  it  is  very  certain  that,  to  whatever  condition,  local  or  con¬ 
stitutional,  non-union  of  a  fracture  may  be  due,  it  is  in  very  many  cases 
quite  impossible  to  assign  to  it  any  cause  appreciable  b}'  the  Surgeon. 

The  Treatment  of  ununited  fracture  must  not  be  conducted  by  local 
means  only  ;  constitutional  measures  should  not  be  neglected.  We  can¬ 
not  expect  the  formation  of  firm  and  strong  callus  unless  the  general 
health  be  in  a  satisfactory  state.  If  callus  have  not  been  formed,  or  if, 
after  formation,  it  have  been  absorbed  under  the  influence  of  a  cachectic 
state  of  the  system,  the  improvement  of  the  patient’s  health,  at  the  same 
time  that  the  fracture  is  put  up  again  firmly,  so  that  the  ends  of  the 
bone  are  brought  into  close  apposition,  may  bring  about  perfect  union. 
I  have  had  under  my  care  at  the  Hospital,  a  man  with  ununited  fracture 


UXUNITED  FRACTURE. 


337 


of  the  femur  from  absorption  of  the  callus  four  months  after  the  occur¬ 
rence  of  the  injury,  under  the  influence  of  incipient  phthisis  and  debility 
induced  by  want  of  food  :  perfect  consolidation  of  the  fracture  was  pro¬ 
duced  by  giving  him  cod-liver  oil  and  good  diet,  with  rest  in  bed  and  a 
starched  bandage  to  the  limb.  Hence  it  is  evident  that  impaired  nutri¬ 
tion  ma}^  prevent  union,  even  after  a  fracture  has  become  consolidated, 
and  that  improvement  of  the  nutritive  activity  of  the  body  may  of  itself 
lead  to  consolidation  of  the  fragments.  If  there  be  no  very  evident 
cause  for  the  want  of  union,  it  will  occasionally  suffice  to  put  up  the 
fracture  firmly  in  leather  or  gutta-percha  splints,  with  a  starched  bandage, 
and  then  to  allow  the  patient  to  move  about  upon  crutches,  so  that  his 
general  health  ma}'  not  suffer,  at  the  same  time  that  a  tonic  plan  of 
treatment  is  followed.  I  have  seen  several  cases  in  which  the  want  of 
union  appeared  to  have  resulted  from  too  long  confinement  of  the  patient 
to  his  bed,  and  the  consequent  impairment  of  his  health,  consolidation 
taking  place  when  a  more  favorable  h3'gienic  system  was  enforced.  This 
simple  plan  can,  however,  onl}"  be  useful  if  but  a  short  time,  at  most 
some  months,  have  elapsed  from  the  occurrence  of  the  injuiy.  In  some 
cases,  the  empirical  administration  of  mercury  is  attended  with  success. 
In  a  case  of  ununited  fracture  of  the  humerus  that  was  admitted  into 
the  University  College  Hospital  under  Liston,  fifteen  weeks  after  the 
occurrence  of  the  injuiy,  union  was  induced  within  a  month  by  putting 
up  the  limb  in  splints,  and  salivating  the  patient.  When  the  want  of 
union  arises  from  malignant  disease,  nothing  can  be  done. 

At  the  same  time,  with  appropriate  constitutional  treatment,  suitable 
local  means  must  be  emplo^^ed  to  secure  steady"  coaptation  of  the  frag¬ 
ments.  In  the  upper  extremit}’,  this  ma}’  usually  be  done  by  means  of 
splints  of  an  ordinary  character.  In  the  leg,  the  starched  or  plaster  of 
Paris  bandage  will  be  found  to  be  especial service¬ 
able.  In  the  case  of  ununited  fracture  of  the  thigh, 
special  apparatus  will  be  required  to  secure  complete 
fixity  and  steadiness  of  the  limb.  For  this  purpose, 
the  limb  should  be  put  in  an  apparatus,  consisting  of 
an  outer  and  an  inner  iron  rod  having  hinge-joints  oppo¬ 
site  the  hip  and  ankle,  and  attached  above  to  a  strong 
pelvic  band,  and  below  to  the  sole  of  the  boot.  The  thigh 
part  should  be  provided  with  well-padded  splints,  which 
ma}'  be  screwed  down  in  opposite  directions  against 
the  two  fragments,  so  as  to  hold  them  firmW  in  con¬ 
tact.  This  instrument  should  be  worn  for  several 
months ;  and  by  it  Smith,  of  Philadelphia,  has  suc¬ 
ceeded  in  curing  ten  out  of  fourteen  ununited  fractures 
in  the  lower  extremity.  One  great  recommendation 
is,  that  this  plan  of  treatment  is  entirel}^  devoid  of 
danger,  and  enables  the  patient  to  take  exercise  whilst 
under  treatment.  In  cases  where  there  are  much 
shortening  of  the  limb  and  riding  of  the  fragments, 
which  is  especiall}"  apt  to  occur  in  the  thigh,  it  will  be 
necessary  to  employ*  extension  of  the  limb  as  well  as 
compression  of  the  fragments  against  one  another. 

This  extension  may  be  made  by  the  lateral  iron  rods 
of  the  above-described  apparatus  being  constructed  so 
as  to  slide,  by  means  of  a  rack  and  pinion  or  screw 
mechanism,  b}’’  which  the  limb  may  be  gradually 
lengthened  to  any  required  extent  (Fig.  126). 

VOL.  I. — 22 


Fig.  126. 


Fracture  of  Femur. 


838 


FRACTURES. 


When  the  failure  of  union  has  become  veiy  chronic,  and  a  false  joint 
has  been  formed,  it  will  be  necessary  to  emplo}’  operative  procedure 
before  union  can  be  attained.  All  operations  that  are  undertaken  in 
these  cases  are  conducted  on  one  of  two  principles;  either,  1,  to  excite 
such  inflammation  in  the  false  joint  and  the  neighboring  tissues,  as  will 
lead  to  the  formation  of  lymph  capable  of  undergoing  osseous  transfor¬ 
mation  ;  or  else,  2,  by  removing  the  false  joint  altogether^  to  convert  the 
case  into  a  recent  compound  fracture,  and  to  treat  it  as  such  an  accident. 
It  can  be  easily  understood  that  operative  procedures  conducted  on  these 
principles  are  too  serious  to  be  lightly  undertaken,  or  to  be  had  recourse 
to  until  other  measures  have  failed,  the  mortalit}^  following  them  being, 
even  according  to  public  statistics,  considerable,  and  probably  very  much 
greater  than  has  been  laid  before  the  profession. 

1.  Among  the  first  set  of  operations, — those  that  have  in  view  the 
Excitation  of  sufficient  Inflammation  to  cause  Deposit  of  proper  Plastic 
Matter^ — the  simplest  procedure  consists  in  the  introduction  of  acupunc¬ 
ture  needles^  or  in  the  subcutaneous  section  of  the  ligamentous  band  with 
a  tenetome.  In  this  way  I  have  known  union  effected  in  a  patient  of 
Liston’s,  who  had  a  false  joint  in  the  shaft  of  the  femur;  though  not 
until  after  the  fracture  had  been  converted  into  a  compound  one,  and 
much  danger  and  sufifering  incurred.  Four  years  after  the  consolidation 
of  the  uuunited  fracture,  the  patient  was  readmitted  into  the  Hospital, 
under  my  care,  with  fracture  of  the  same  bone  tw^o  inches  lower  down 
than  the  former  injury;  on  this  occasion,  union  took  place  in  the  usual 
manner  and  time  without  any  difficult3^ 

The  introduction  of  a  Seton  across  the  false  joint,  though  occasionally 
successful,  is  apt  to  give  rise  to  dangerous  and  even  fatal  results,  from 
arterial  hemorrhage,  erysijDelas,  difluse  inflammation,  and  suppuration 
of  the  limb.  The  threads  must  not  be  left  in  beyond  a  few  days,  when 
sufficient  action  will  have  been  induced.  A  modification  of  the  seton 
consists  in  passing  a  silver  wire  around  the  fracture,  and  gradually 
tightening  this,  so  as  to  cut  through  the  false  joint  at  the  same  time 
that  inflammatory  action  is  excited  in  it.  In  performing  this  operation, 
it  must  be  borne  in  mind  that  large  arterial  branches,  and  even  the  main 
trunk,  especiall}'  in  the  thigh,  ma}’’  become  firmly  attached  to  the  callus, 
so  that  unless  care  be  taken  they  may  readily  be  wounded. 

Diffenbach  has  proposed  to  excite  the  requisite  degree  of  inflammation 
■by  driving^  ivith  a  mallet^  three  or  four  conical  ivory  pegs  into  holes 


Fig.  127. 


bored  by  means  of  a  gimlet  or  drill  in  the  ends  of  the  fractured  bone, 
which  are  exposed  for  this  purpose.  The  awl,  or  drill,  may  be  worked 
with  the  Archimedean  screw,  and  will  then  be  found  to  penetrate  much 
more  easily.  Points  of  different  sizes  may  be  used,  and  altogether  this 


TREATMENT  OF  UNUNITED  FRACTURES. 


3c9 


instrument  will  be  found  by  far  the  best  (Fig.  12T).  The  soft  parts 
are  then  to  be  laid  down,  and  after  a  few  weeks  the  pegs,  which  have 
loosened  in  consequence  of  the  removal  or  absorption  of  their  ends, 
should  be  taken  out.  It  is  not  necessary  or  even  desirable  to  endeavor 
to  pin  together  the  ends  of  the  broken  bone,  but  merely  to  introduce  the 
pegs  into  the  extremities  of  both  fragments  near  to  the  seat  of  fracture. 
It  is,  however,  especially  in  ununited  fractures  of  the  humerus,  that  this 
can  be  successful!}-  done,  the  irritation  of  the  pegs  appearing  to  occasion 
an  effusion  of  a  large  quantity  of  callus  sufficient  for  the  consolidation 
of  the  fracture.  This  operation  I  have  practised  with  great  success  in 
several  instances  of  ununited  fracture  of  this  bone.  In  one  case  that 
was  under  my  care,  there  was  a  false  joint  at  the  junction  of  the  upper 
and  middle  thirds  of  the  bone,  complicated  with  an  elbow  ank^dosed  in 
the  straight  position ;  here  after  flexion  of  the  stiff  elbow,  perfect  con¬ 
solidation  of  the  humerus  was  effected  by  the  use  of  five  pins.  In  the 
ununited  fractures  of  the  bones  of  the  leg  and  forearm,  it  is  also  likely 
to  be  serviceable,  but  in  the  femur  not  so  much  so.  Indeed,  in  the 
cases  of  ununited  fracture  of  this  bone,  I  have  known  more  failures  than 
successes  after  this  operation. 

2.  The  operation  of  Removing  the  False  Joint  may  be  performed  b}’’ 
cutting  down  upon  it,  and  resecting  the  ends  of  the  bones,  or  else  by 
destro3-ing  the  articulation  with  caustic  potass.  The  excision  of  a  false 
joint  is  necessaril}-  dangerous,  and  by  no  means  successful;  eiysipelas, 
phlebitis,  and  diffuse  suppuration  of  the  bone,  occasional!}-  supervening. 
It  should  only  be  done  when  there  is  much  overlapping  of  the  fragments. 
Of  39  cases  collected  by  Xorris,  in  which  the  ends  of  the  bones  were 
either  resected  or  scraped,  24  were  cured,  7  derived  no  benefit,  and  6 
died.  In  those  cases  of  the  operation  that  are  successful,  some  shorten¬ 
ing  of  the  limb  must  be  expected  to  result ;  and,  if  the  fracture  be  very 
oblique,  it  will  of  course  be  impossible  to  remove  more  than  a  very 
limited  portion  of  bone,  and  consequently,  very  perfect  union  can 
scarcely  be  anticipated.  The  application  of  caustics  to  the  exposed 
bones  is  so  coarse  and  uncertain  a  method  as  to  find  but  little  favor 
amongst  Surgeons  of  the  present  day. 

On  reviewing  the  various  methods  that  have  been  recommended  for 
the  re-establishment  of  union  between  the  separated  fragments,  it  would 
appear  that  the  excitation  of  proper  inflammatory  action  by  the  intro¬ 
duction  of  the  seton,  or  by  driving  in  ivory  pegs,  promises  the  most 
satisfactory  result.  It  is  by  no  means  necessary,  or  even  advisable,  to 
remove  the  fibrous  band  that  intervenes  between  the  fragments  in  cases 
of  false 'joint for,  if  the  proper  amount  of  inflammatory  action  be  set 
up,  this  either  undergoes  osseous  transformation,  or  a  sufficient  quantity 
of  callus  is  thrown  out  around  it  to  consolidate  the  fracture.  If  union 
should  fail  to  be  accomplished,  and  the  false  joint  were  situated  in  the 
femur  or  the  bones  of  the  les:,  the  limb  might  be  so  useless  and  cum- 
bersome  to  the  patient,  that  amputation  might  be  required  as  a  last 
resource. 


340 


SPECIAL  FRACTURES. 


CHAPTER  XXI. 

SPECIAL  FRACTURES. 

In  considering  the  nature  and  treatment  of  fractures  of  particular 
bones,  we  shall  at  present  confine  our  remarks  to  Fractures  of  the  Bones 
of  the  Face,  Trunk  and  Extremities.  Injuries  of  the  Bones  of  the  Head 
and  Spine  derive  their  prineipal  interest  and  importance  from  their 
complication  with  lesion  of  the  internal  and  contained  organs;  hence 
the  consideration  of  these  will  be  deferred  to  special  Chapters. 

FRACTURES  OF  THE  BONES  OF  THE  FACE. 

Nasal  Bones. — These,  being  thin  as  well  as  exposed,  are  not  unfre- 
quently  broken.  When  fractured,  they  may  remain  undisplaced,  but 
are  more  commonly  depressed;  the  ridge  of  the  nose  being  beaten  in. 
The  swelling  and  ecchymosis  that  usually  attend  their  fracture  often 
render  detection  difficult,  and  must  be  reduced  before  any  treatment 
can  be  adopted  for  the  removal  of  the  deformity.  The  depressed  bone 
should  be  raised  with  the  broad  end  of  a  director,  or  by  the  introduction 
into  the  nostril  of  a  pair  of  polypus-forceps,  wdiich,  expanding  on  open¬ 
ing,  push  the  bone  into  proper  position.  A  fluid  vulcanized  India-rubber 
dilator,  of  proper  size  and  shape,  introduced  empty,  and  then  expanded 
by  the  action  of  water,  will  be  found  to  answer  admirably  in  restoring 
the  shape,  and  removing  the  disfigurement  of  a  “  broken  nose,”  even 
though  some  weeks  have  elapsed  since  the  injury. 

If  the  septum  alone  be  broken,  the  same  treatment  must  be  adopted ; 
the  nose  being  supported  and  moulded  into  shape.  Usually,  after  it  has 
been  replaced,  the  position  is  maintained :  but  in  some  cases,  where  there 
is  a  tendency  to  sinking  of  the  soft  parts  of  the  nose,  the  introduction 
of  a  plug  of  oiled  lint  round  a  quill,  left  open  for  breathing,  will  be 
required  to  replace  and  retain  the  organ  in  proper  shape  and  promi¬ 
nence.  The  hemorrhage,  which  is  usually  rather  abundant  in  the  first 
instance,  ma}’'  be  stopped  by  the  application  of  ice ;  but  occasionally  the 
nostrils  require  plugging,  in  order  to  prevent  it  from  continuing  to  a 
dangerous  extent.  If  the  lachrymal  hone  be  broken  together  with  the 
nasal,  the  ductus  ad  nasum  may  be  obstructed,  and  the  course  of  the 
tears  diverted.  In  an  injury  of  this  kind,  I  have  seen  extensive  em¬ 
physema  of  the  eyelids  and  forehead  occur  on  the  patient  attempting  to 
blow  his  nose.  In  some  cases,  the  injuiy  inflicted  on  the  nasal  bones 
extends  through  the  ethmoid  to  the  base  of  the  brain,  and  may  thus 
occasion  death.  This  I  have  seen  happen  from  a  severe  blow  on  the  face 
with  a  piece  of  wood. 

Malar  and  Upper  Jaw  Bones. — These  are  seldom  broken  unless 
great  and  direct  violence  have  been  employed;  and  their  fracture  is 
usually  accompanied  by  external  wound,  as  in  gunshot  injuries  of  these 
parts.  More  commonly  the  alveolar  processes  are  detached,  and  the 
teeth  loosened.  The  treatment  then  consists  in  binding  the  teeth 
together  with  gold  wire.  In  fractures  of  the  zygoma^  the  fragments  may 


4 


FRACTURES  OF  THE  BONES  OF  THE  FACE. 


341 


be  driven  into  the  temporal  muscle,  and  produce  so  much  difficulty  in 
mastication  as  to  require  removal. 

In  some  rare  cases,  all  the  bones  of  the  face  appear  to  have  been 
smashed,  and  separated  from  the  skull  by  the  infliction  of  great  violence. 
Thus,  South  relates  the  case  of  a  man  who  was  struck  on  the  face  with 
a  handle  of  a  crane,  and  in  whom  all  the  bones  w'ere  separated  and 
loosened,  “feeling  like  beans  in  a  bag.”  Tidal  records  the  case  of  a  man, 
who,  by  a  fall  from  a  great  height,  separated  all  his  facial  bones.  A 
patient  was  admitted  into  University  College  Hospital  under  my  care, 
who  had  fallen  thirty  feet  over  the  balusters  of  a  spiral  staircase.  He 
had  in  some  way  struck  his  face,  either  on  reaching  the  ground  or  in  the 
fall.  He  lived  only  about  two  hours  after  admission.  On  making  a 
post-mortem  examination,  the  following  injuries  were  found.  The  lower 
jaw  was  fractured  through  the  ramus  on  the  left  side,  and  through  the 
body  between  the  molar  teeth  on  the  right  side.  In  the  upper  jaw  a 
transverse  fracture  ran  completely  across  from  one  side  of  the  face  to 
the  other,  at  about  the  level  of  the  inferior  border  of  the  anterior  nares. 
It  passed  through  both  superior  maxillary  bones,  the  vertical  part  of 
the  palate  bones,  both  pterygoid  processes  of  the  sphenoid  bone  on  both 
sides,  and  the  vomer:  so  that  the  whole  of  the  alveolar  portions  of  the 
superior  maxilla  and  the  palate  formed  one  piece.  This  was  displaced 
backwards  into  the  phaiynx.  The  zygoma  was  fractured  on  both  sides ; 
and  a  vertical  •fracture  ran  on  each  side  from  the  margin  of  the  orbit 
through  the  walls  of  the  antrum ;  so  that  on  each  side  there  was  one 
huge  fragment  composed  of  part  of  the  zygoma,  the  malar  bone,  and 
the  part  of  the  superior  maxillary  bone  with  which  it  is  articulated. 
The  nasal  bones,  nasal  processes  of  the  superior  maxillary  bones,  as  the 
os  unguis  on  each  side,  and  the  ethmoid,  w^ere  smashed  into  numerous 
small  frao:ments.  There  was  no  fracture  visible  from  the  interior  of  the 
skull.  There  were  no  other  injuries  of  importance  found. 

In  Gunshot  Injuries  of  the  Face^  there  is  usualty  great  splintering  of 
the  bone.-  As,  however,  the  vitality  of  the  part  is  great,  necrosis  is  not 
so  likely  to  ensue  here  as  elsewhere ;  and  the  partially  detached  and 
loosened  fragments  ma}’-  accordingly  be  put  back  into  position,  and 
will  usually  recover  themselves.  There  are,  however,  two  principal 
dangers  in  these  cases ;  viz.,  hemorrhage,  either  primary  or  secondaiy, 
and  abundant  fetid  muco-puriform  discharge.  The  primary  hemorrhage 
usuallj’’  ceases  spontaneous!}^,  or  on  the  application  of  cold.  If  secondary, 
it  may  be  arrested  by  cold,  by  plugging,  and  by  pressure;  or,  if  con¬ 
tinuous,  and  from  deep  sources,  may  possibly  require  ligature  of  the 
carotid.  The  fetid  secretion  from  these  wounds  is  not  only  a  source  of 
great  discomfort  to  the  patient,  but  of  positive  danger,  as,  by  its  mias¬ 
matic  effiuvia,  or  by  finding  its  way  into  the  stomach,  it  may  occasion 
typhoid  symptoms.  This  risk  is  best  obviated  by  scrupulous  attention 
to  cleanliness,  by  repeated  injections  with  warm  water  or  chlorinated 
lotions. 

Lower  Jaw. — This  bone  is  frequently  broken,  owing  to  its  prominent 
situation;  though  its  arched  shape  enables  it  to  resist  all  but  extreme 
degrees  of  violence.  Fractures  of  this  bone  are  often  compound,  some¬ 
times  in  consequence  of  external  wound,  but  more  frequently  from  the 
laceration  of  the  gum  causing  them  to  communicate  with  the  external 
air.  Not  unfrequently,  they  are  comminuted. 

Fracture  of  the  lower  jaw  may  occur  in  various  situations.  I  have 
seen  it  most  frequently  in  the  body  of  the  hone  near  the  symphysis, 
extending  between  the  lateral  incisor  and  the  canine  teeth.  The  symphysis 


342 


SPECIAL  FEACTUEES. 


itself  is  not  so  comnronly  fractured,  the  bone  being  thick  in  this  situation. 
The  angle  is  more  frequently  broken.  The  coronoid  process  can  only 
suffer  fracture  from  the  most  severe  and  direct  external  injury,  as  from 
a  bullet  wound.  The  neck  of  the  condyle  is  occasionally  broken  across. 

Fractures  near  the  symphysis  are  usually  vertical.  Those  near  the 
angle  are  commonly  oblique  from  before  backwards,  so  that  a  long 
spiculum  of  the  outer  table  is  connected  with  the  upper  fragment. 

These  fractures  are  sometimes  double,  either  symmetrically  so,  or 
more  frequently  one  on  the  side  near  the  symphj’sis,  and  the  other  near 
the  anomie. 

o  _ 

The  Signs  of  fracture  of  the  lower  jaw  are  very  obvious.  The  great 
mobility  of  the  fragments,  the  crepitus,  the  irregularity  of  the  line  of 
teeth  and  of  the  arch  of  the  jaw,  laceration  of  and  bleeding  from  the 
gums,  and  dribbling  of  saliva,  indicate  unequivocally  the  nature  of  the 
injury.  The  displacement  and  mobility  of  the  fracture  are  greater,  the 
nearer  it  is  to  the  symphysis.  If  the  bone  happen  to  be  broken  on  both 
sides  of  this  line,  the  middle  fragment  is  much  dragged  out  of  place  by 
the  depressor  muscles  attached  to  it;  indeed,  in  all  double  fractures  the 
displacement  is  very  great.  In  fracture  about  the  angle  and  lower  part 
of  the  ramus,  the  deformity  is  not  so  great,  owing  to  the  muscles  that 
coat  and  protect  each  side  of  the  bone  in  this  situation  preventing  the 
fragments  from  being  displaced.  When  the  neck  of  the  cond3de  is 
broken  through,  that  process,  coming  under  the  influence  of  the  external 
pteiygoid  muscle,  is  often  a  great  deal  displaced. 

When  the  fracture  is  near  the  symphysis,  the  dental  canal  escapes  ;  but 
when  it  is  further  back  in  the  bod}^  of  the  bone,  and  especially"  near  the 
angle,  the  canal  must  necessarily  be  implicated.  It  is  remarkable,  how¬ 
ever,  that  the  inferior  dental  nerve  usually  escapes  injury  or  division  in 
many-  cases  altogether,  in  others  for  several  days,  until,  perhaps,  owing 
to  great  displacement  or  to  some  effort  of  reduction,  it  may  be  torn 
across.  When  this  happens,  the  soft  parts  of  the  lower  lip,  supplied  by 
the  mental  branch  of  the  inferior  dental,  are  necessarily"  for  a  time  deprived 
of  sensation,  but  they  soon  recover.  I  have  never  known  any  permanent 
mischief  from  this  cause,  or  from  the  hemorrhage  following  laceration  of 
the  inferior  dental  artery. 

The  Treatment  is  simple  enough  in  principle,  though  often  not  very 
easy  of  accomplishment.  It  consists  in  maintaining  the  parts  in  appo¬ 
sition  by  suitable  apparatus  for  four  or  flve  weeks,  during  which  time 
mastication  must  be  interdicted,  the  patient  living  on  sops,  soups,  and 

Fig.  128. 

dr^ 

r  d 

Gutta  Percha  Splint:  Original  Shape. 

fluid  nourishment  of  all  kinds,  and  talking  being  prohibited.  The  appa¬ 
ratus  that  commonly"  suffices  consists  of  a  gutta-percha  splint  (Fig.  128), 
moulded  to  the  part  (Fig.  129),  properly"  padded,  and  fixed  on  with  a 
four-tailed  bandage  ;  the  two  fore-ends  of  which  are  tied  behind  the 


Fig.  129. 


Gutta  Percha  Splint  moulded  to 
Shape  of  Jaw. 


FRACTURES  OF  THE  LOWER  JAW. 


343 


Fig.  130. 


Apparatus  applied  to  Fracture 
of  Lower  Jaw. 


neck,  whilst  the  other  two  are  knotted  over  the  top  of  the  head  (Fig. 
130).  When  the  ramus  is  broken,  the  side  of  the  gutta-percha  cup  splint 
should  be  made  proportionately  long.  The  teeth  in  these  cases  require 
special  attention.  Any  that  are  loosened  must 
be  left  in,  as  they  will  soon  contract  adhesions, 
and  fix  themselves  firmly ;  and  if  necessary,  they 
may  be  tied  to  the  sound  teeth  with  silver  wire, 
or  dentist’s  silk.  But  although  metallic  wire  is 
occasionally  needed  for  the  purpose  of  securing 
loosened  teeth,  it  is  of  no  service  in  tjing  to¬ 
gether  the  teeth  for  the  purpose  of  more  accu¬ 
rately  fixing  the  broken  fragments.  Care  must 
be  taken  that  any  tooth  that  may  have  been 
forced  out  of  its  alveolus  and  dropped  between 
the  fragments  be  removed  from  this  situation  ; 
in  one  case  where  a  tooth  was  overlooked  in  this 
position,  no  union  of  the  fracture  took  place  till 
it  had  been  removed.  When  depression,  espe¬ 
cially  near  the  symphysis,  is  considerable,  a  clamp 
apparatus  which  fixes  the  chin  and  line  of  teeth, 

invented  b}^  Lonsdale,  answers  the  purpose  of  steadying  tlie  fragments 
extremely  well.  When  the  fracture  is  double,  one  fissure  occurring  near 
the  S3"mphysis,  the  other  near  the  angle,  there  is  often  very  considerable 
difficult}^  in  bringing  the  fragments  into  an\Thing  like  good  position, 
without  the  aid  of  some  special  apparatus.  In  such  cases  a  metal  plate 
should  be  accurately  moulded  and  fitted  to  the  teeth,  and  attached  to 
Lonsdale’s  clamp  or  to  a  stem,  and  fixed  to  a  horseshoe-shaped  gutta¬ 
percha  splint  placed  under  the  jaw,  so  as  to  keep  the  whole  steady"  and 
solid.  L^nion  generally  takes  place  readily  and  very  perfectly"  in  fractures 
of  the  jaw,  though  it  is  somewhat  slow  at  first,  and  the  fragments  con¬ 
tinue  mobile  for  some  weeks.  But  the  vascular  supply  of  the  bone  is 
abundant,  and  reparative  action  correspondingly  perfect. 

In  Fractures  of  the  Body  of  the  Lower  Jaw  by  Gunshot  Injury^  there 
is  great  comminution  and  splintering  of  the  bone,  followed  by  copious 
and  fetid  discharge,  which,  being  in  part  swallowed,  may  reduce  the 
patient  to  a  state  of  extreme  debility,  or  induce  symptoms  of  a  typhoid 
character,  which  maj^  prove  fatal.  In  these  cases  Dupuytren  recommends 
the  lower  lip  to  be  cut  through,  the  splinters  taken  away,  and,  if  necessary 
a  portion  of  the  bone  resected,  so  as  to  convert  the  wound  into  one  simi¬ 
lar  to  what  results  after  the  partial  removal  of  the  lower  jaw  for  disease 
of  the  bone. 

Fracture  of  the  Hyoid  Bone  is  of  very  rare  occurrence ;  and, 
though  usually  the  result  of  direct  violence,  as  a  forcible  grasp,  has  been 
seen  by  Ollivier  D’ Angers  to  occur  from  muscular  action.  The  signs 
are  always  very  obvious.  The  fragments  form  a  sharp  salient  angle ; 
there  is  much  pain  and  irritation,  increased  by  speaking  and  deglutition. 
There  is  usually  salivation;  and  considerable  difficulty  in  breathing  ma^" 
be  present.  Reduction  is  accomplished  by  pressing  the  fragments  into 
apposition,  either  externally  or  by  pressing  the  finger  into  the  mouth. 
Should  one  piece  of  the  bone  be  driven  much  in,  it  might  possibly  require 
to  be  drawn  forwards  with  a  tenaculum.  The  head  should  then  be  fixed 
with  a  stift’  pasteboard  collar  to  prevent  displacement. 


344 


SPECIAL  FEACTURES. 


FRACTURES  OF  THE  BONES  OF  THE  CHEST. 

Fracture  of  the  Ribs  and  Costal  Cartilages. — These  injuries  may 
occur  in  two  ways ;  1st,  from  direct  violence,  the  part  that  is  struck 
being  driven  in  towards  the  thoracic  cavity,  and  thus  broken ;  2d,  the 
fracture  occurs  from  indirect  violence,  the  forepart  of  the  chest  being 
forcibly  compressed,  so  that  the  rib  is  bent  outwards,  and  thus  snaps. 
When  the  injury  is  the  result  of  direct  violence,  and  the  broken  fragments 
are  forced  in,  the  pleura,  lung,  liver,  or  diaphragm  may  be  wounded,  thus 
giving  rise  to  the  most  serious  and  fatal  consequences,  such  as  hemor¬ 
rhage,  emphysema,  and  inflammation  of  the  parts  injured.  When  it  is 
occasioned  by  indirect  violence,  as  the  fracture  takes  place  in  a  direction 
outwards,  the  thoracic  organs  maybe  contused  and  thus  injured,  but 
they  are  not  liable  to  be  punctured  by  the  fragments.  In  some  rare  cases 
the  ribs  have  been  known  to  be  broken  by  the  violent  contraction  of  the 
abdominal  muscles  during  parturient  efforts. 

Fractures  of  the  ribs  may  be  single^  one  only  being  broken;  multiple^ 
several,  or  even  the  whole  of  the  ribs  on  one  side,  or  several  on  both 
sides,  being  fractured ;  simple^  as  in  ordinary  violence;  and  compowncZ, 
as  in  gunshot  injuries. 

Any  one  of  the  ribs  may  be  broken,  and  frequently  several  are  frac¬ 
tured  at  the  same  time.  The  middle  ribs,  from  the  fourth  to  the  eighth, 
are  those  that  most  frequently  give  way,  being  most  exposed,  and  at  the 
same  time  fixed.  The  first  and  second  ribs  are  seldom  broken,  being  pro¬ 
tected  by  the  clavicle  and  shoulder.  When  they  are  fractured  it  is  usu¬ 
ally  the  result  of  gunshot,  or,  if  from  some  of  the  ordinary  accidents  of 
civil  life,  the  clavicle  will  be  broken  as  well.  But  this  is  not  an  invariable 
complication.  I  have  seen  fractures  of  the  first  two  ribs  from  a  fall, 
without  any  injury  to  neighboring  bones.  The  injury  is  always  very 
dangerous,  on  account  of  the  importance  of  the  subjacent  structures. 
The  lower  ribs,  being  less  firmly  fixed  than  the  others,  commonly  escape, 
unless  very  great  and  direct  violence  be  inflicted  upon  them.  Any  part 
of  a  rib  may  be  broken  by  direct  violence ;  but  when  the  fracture  is  the 
result  of  compression  of  the  chest,  it  is  usually  the  convexity  or  the 
neighborhood  of  the  angle  of  the  rib  that  gives  way.  These  indirect 
fractures  most  commonly  occur  in  elderly  people,  in  whom  the  elasticity 
of  the  thoracic  parietes  has  lessened  as  the  result  of  age. 

Symptoms. — The  chief  symptom  complained  of  is  a  sharp  pricking  and 
catching  pain  at  the  seat  of  injury,  increased  by  breathing  deeply,  or  by 
coughing.  In  order  to  avoid  this,  the  inspirations  are  shallow,  and  the 
breathing  is  principally  diaphragmatic  and  abdominal.  On  laying  the 
hand  over  the  seat  of  injury,  and  desiring  the  patient  to  cough,  crepitus 
may  often  be  felt ;  and  in  most  cases  this  is  audible  on  applying  the  ear 
to  the  chest.  Occasionally  the  outline  of  the  rib  will  be  found  to  be 
irregular;  and  in  some  instances,  where  several  ribs  are  broken,  the  whole 
side  of  the  chest  is  flattened  and  depressed.  Besides  these  local  symp¬ 
toms,  special  phenomena  resulting  from  the  complication  of  wound  or 
laceration  of  the  pleura  or  lung,  such  as  spitting  of  blood,  pneumothorax, 
or  emphysema,  may  occur.  These  complications  occur  much  less  fre- 
quentlj'-  than  might  a  priori  be  supposed,  owing  to  the  fracturing  force 
usually  causing  the  rib  to  bend  outwards,  and  thus  to  break  away  from, 
instead  of  into  the  chest.  The  danger  of  fractured  ribs  depends  entirely 
on  the  thoracic  complications,  and  these  will  chiefly  be  occasioned  by 
one  or  two  conditions ;  either  by  the  forcible  driving  in  of  the  fractured 
end  of  one  rib,  so  that  the  pleura  and  lung  become  wounded  by  the  sharp 


FRACTURES  OF  THE  RIBS. 


345 


and  ragged  ends  of  the  fragment ;  or  else  by  a  large  number  of  ribs  being 
broken  by  a  severe  squeeze  of  the  chest,  and  the  thoracic  organs  injured 
by  the  general  compression.  It  is  surprising,  however,  what  an  extent 
of  injury  of  this  kind  may  take  place  without  serious  consequences.  I 
have  had  under  my  care  a  3’'oimg  man,  who,  in  consequence  of  a  crush  of 
the  chest,  in  a  railway'  accident,  had  the  upper  sev^en  ribs  broken  on  the 
right  side,  and  the  lower  five  on  the  left,  the  chest,  especially  on  the  right 
side,  being  greatlj^  flattened  ;  he  recovered  without  a  bad  syunptom.  In 
gunshot  injuries  of  the  chest,  with  splintering  of  the  ribs,  there  is  alwa3’s 
wound  of  the  contained  origans,  which  becomes  the  main  source  of  danger 
to  the  patient  and  of  attention  on  the  part  of  the  Surgeon. 

Treatment. — In  treating  fractured  ribs,  the  Surgeon  need  not  concern 
himself  so  much  about  the  union  of  the  fracture,  as  about  the  prevention 
of  pain  to  the  patient  in  breathing,  and  of  the  subsequent  occurrence  of 
serious  inflammation  or  other  mischief  within  the  chest. 

Any  displacement  that  ma3"  exist  usuall3"  remedies  itself.  The  chest- 
wall,  even  when  extensively  flattened,  graduall3’’  expands  under  the  in¬ 
fluence  of  the  respiratoiy  movements.  If,  however,  a  portion  of  the  rib 
continue  depressed,  it  had  most  certainly  better  be  left  so ;  the  sugges¬ 
tions  that  have  been  made  for  elevating  these  fractures  b3nueans  of  sharp 
hooks  and  screw-probes,  being  more  likel3^  than  the  continuance  of  the 
depression  to  occasion  serious  mischief  to  the  contents  of  the  thorax. 
In  order  to  prevent  undue  motion  of  the  broken  bone  and  consequent 
irritation  produced  by  its  puncturing  the  pleura,  or  lung,  the  movements 
of  the  injured  part  of  the  chest  may  be  restrained  by  the  application  of 
a  broad  flannel  roller,  or  of  a  laced  napkin  around  it.  Instead  of,  or  in 
addition  to  these  means,  it  will  be  found  most  useful  to  apply  a  roll  of 
adhesive  plaster  around  the  chest.  The  plaster  must  be  about  a  foot  in 
width,  and  should  be  sufficiently  long  to  make  one  and  a  half  turns 
around  the  body.  It  should  be  applied  very  tightly,  and  may  be  left  on 
for  ten  days  or  a  fortnight,  when  it  may  require  reapplication.  It  sup¬ 
ports  the  chest  more  firml3'’  and  evenly  than  an  ordinary  bandage,  afford¬ 
ing  the  patient  great  comfort.  In  some  cases,  however,  more  particu¬ 
larly  in  those  in  which  the  fragments  are  driven  inwards,  it  will  be  found 
that  the  constriction  of  the  chest,  by  bandage  or  plaster,  becomes  un¬ 
bearable  to  the  patient,  producing  great  pain  and  intense  d3’-spnoea.  In 
these  circumstances  all  constriction  must  be  removed,  and  the  patient 
be  allowed  to  breathe  easily,  but  he  must  be  confined  to  bed.  If  the 
lower  ribs  be  broken,  the  diaphragm  may  become  irritated  by  the  pro¬ 
jection  inwards  of  the  fractured  bone  ;  and  if  the  plaster  and  bandage 
be  applied  too  tightly,  spasmodic  action  of  that  muscle  may"  ensue, 
occasioning  distressing  dyspnoea. 

In  gunshot  injuries  of  the  chest  with  splintering  of  the  ribs,  all  broken 
spicula  of  bone  must  be  carefully  picked  out,  and  the  wound  lightly 
covered  with  water-dressing.  In  such  cases,  the  grave  injuries  usually 
sustained  by^  the  intrathoracic  organs  will  absorb  the  Surgeon’s  attention ; 
and  for  their  treatment  I  must  refer  to  Chapter  XXYIII. 

The  prevention  of  inflammatory  action  must  be  attempted,  by  the  em¬ 
ployment  of  bleeding  if  necessary ;  but  certainly  by  the  adoption  of  a 
spare  diet  and  complete  rest.  Any'-  complications  that  may  occur,  such 
as  emphysema,  or  inflammation  of  the  lungs  or  pleura,  must  be  treated 
in  accordance  with  the  principles  that  will  be  laid  down  in  speaking  of 
Injuries  of  the  Chest  generally. 

It  occasionally  happens  that  fracture  of  one  or  more  of  the  Costal 
Cartilages.^  especially  the  fifth,  sixth,  seventh,  or  eighth,  is  produced  by 


346 


SPECIAL  FRACTURES. 


direct  violence.  They  may  be  separated  from  their  junction  with  the  rib, 
or  broken  across  the  middle.  The  existence  of  fracture  may  be  deter¬ 
mined  by  the  pain  on  pressure,  mobility  and  irregularity-  at  the  seat  of 
injury.  The  same  treatment  is  required  for  this  fracture  as  for  a  broken 
rib-;  the  broken  cartilage  most  commonly^  uniting  by’’ a  bony  callus  which 
surrounds  the  fractured  ends. 

Fracture  of  the  Sternum. — The  sternum  is  not  often  broken.  Its 
fracture  usually  occurs  from  veiy  severe  and  direct  violence ;  and  when 
this  is  applied  on  the  forepart  of  the  chest,  the  ribs  or  costal  cartilages 
are  more  liable  to  sutfer.  It  may  also  be  produced  by^  violent  bending 
forward  of  the  body  after  the  spine  has  been  broken.  The  elastic  sup¬ 
port  furnished  to  the  sternum  by’’  these  structures,  explains  in  a  great 
measure  the  rarity^  of  its  fracture.  It  has  been  known  to  be  broken, 
though  veiy  rarely,  by’’  violent  straining  muscular  efforts  during  partu¬ 
rition.  Its  fractures  are  always  transverse,  usually’’  single,  but  sometimes 
multiple.  I  have  seen  it  broken  into  three  nearly^  equal  fragments  by’’  a 
fall  from  a  scaffold.  The  displacement  of  one  of  the  fragments  is  some¬ 
times  considerable  ;  but  even  if  it  be  not,  the  very  superficial  situation 
of  the  bone  wull  always  enable  the  Surgeon  to  judge  of  the  exact  nature 
of  the  injury  it  has  sustained,  the  signs  of  which  resemble  those  of  a 
fractured  rib. 

The  Treatment  must  be  conducted  on  the  same  principles  as  in  a 
broken  rib,  and  presents  nothing  deserving  of  special  attention.  Indeed, 
when  fracture  of  the  sternum  occurs  from  external  violence,  it  is  com¬ 
monly  associated  with  fracture  of  the  ribs,  near  the  angles;  and  then  the 
chest-bandage  or  plaster  answers  equally  for  both  injuries.  Should  the 
sternum  be  broken  during  parturition,  the  patient  should  be  made  to  sit 
up  in  bed,  wuth  the  shoulders  supported  and  leaning  forwards  slightly”, 
so  as  to  take  off  the  tension  of  the  abdominal  muscles.  If  a  portion  of 
broken  sternum  be  depressed,  it  should  be  left  undisturbed.  It  will  give 
rise  to  no  serious  inconvenience,  while  any  attempt  to  raise  it  by  sur¬ 
gical  interference  may  be  attended  with  the  greatest  danger. 

FRACTURES  OF  THE  UPPER  EXTREMITY. 

The  Clavicle  is  often  broken,  for  three  reasons:  first,  it  is  exposed 
to  direct  violence  ;  secondly’,  it  receives  all  shocks  transmitted  through 
the  shoulder  in  a  horizontal  direction  to  the  trunk  ;  and  thirdly,  being 
the  only’  direct  osseous  support  of  the  upper  extremity,  it  receives,  by 
transmission  through  the  scapula,  every  shock  that  is  communicated  to 
the  hand  when  the  arm  is  extended.  Notwithstanding  its  exposed 
position,  it  is  comparatively  seldom  broken  by’  direct  injury,  but  it  far 
more  often  is  fractured  by  indirect  violence,  as  blows  on  the  shoulder 
and  falls  on  the  hand.  This  bone  would  be  more  frequently  broken  than 
it  is,  were  it  not  that  it  resembles  two  segments  of  a  circle  looking  in 
opposite  direction,  so  as  to  form  an  S  shape,  which  admirably  enables  it 
to  withstand  indirect  violence. 

The  clavicle  is  occasionally  fractured  by  muscular  action — more  parti¬ 
cularly’  by  back-handed  blows;  when  the  accident  occurs  from  this  cause, 
it  is  usually’  about  the  middle  of  the  bone,  and  on  the  right  side. 

Fractures  from  direct  violence  are  usually’  transverse  or  comminuted. 
F rom  indirect  violence  they  are  oblique.  The  latter  are  attended  by  much 
more  deformity  than  the  former. 

Fractures  of  this  bone  in  infants  and  young  children  are  usually  trans¬ 
verse,  and  sometimes  the  bone  is  merely  bent,  or  is  fractured  on  one  side 


FKACTUKES  OF  THE  CLAVICLE. 


847 


onl}^  The  injury  is  usually  occasioned  by  falling  out  of  bed.  Such 
accidents  are  frequently  overlooked  by  careless  nurses;  but,  the  child 
crying  whenever  the  arm  is  moved,  attention  is  directed  to  the  part,  and 
the  Surgeon  then  finds  some  deformity,  with  a  node-like  swelling  above 
the  middle  of  the  bone. 

Both  clavicles  are  occasionally,  though  rarely,  fractured.  In  one  such 
case,  which  was  under  my  care  at  University  College  Hospital  in  1861, 
the  patient,  a  young  man  of  20,  had  sustained  this  injury,  and  had  twelve 
ribs  broken  as  well,  in  a  railway  accident.  Notwithstanding  this  serious 
complication,  he  made  an  excellent  recovery. 

The  clavicle  may  be  fractured  at  any  point  between  the  ligaments  at 
its  acromial  and  sternal  ends.  1.  Most  frequently  the  Great  Convexity 
is  broken ;  the  bone  bending  here  when  pressed  upon  from  its  extremit}^, 
the  curve  becoming  increased,  and  at  last  giving  wa3\  This  fracture 
ma}^  arise  from  direct  violence,  but  usually  is  the  result  of  falls  on  the 
hand  or  shoulder.  2.  It  ma}’^  be  fractured  nearer  the  acromion,  between 
the  two  Coraco-clamcular  Ligaments.  3.  Its  Tip  may  be  broken  off' 
externally  to  the  outermost  point  of  insertion  of  the  trapezoid  ligament, 
between  it  and  the  acromion.  These  latter  two  fractures  can  scarcely 
occur  from  indirect,  but  are  almost  alwaj^s  the  result  of  direct  violence. 
4.  The  clavicle  may  be  broken  internally,  that  is,  to  the  Sternal  Side  of 
the  Rhomboid  Ligament.,  usually'  about  three-quarters  of  an  inch  from  its 
sternal  articulation.  This  injury  is  of  very  rare  occurrence.  R.  W. 
Smith,  although  admitting  its  possibilit}’^,  states  that  there  is  no  actual 
proof  from  dissection  of  its  having  occurred. 

The  Signs  will  depend  upon  the  seat  of  fracture.  When  the  bone  is 
broken  between  the  conoid  and  trapezoid  ligaments.,  there  is  little  if  any 
displacement,  but  pain  on  pressure,  some  crepitus 
on  moving  the  shoulders,  and  slight  irregularity 
in  running  the  finger  along  the  bone.  When  the 
fracture  is  external  to  the  trapezoid  ligaments.,  there 
is  a  remarkabl}’  oblique  displacement  of  the  scapu¬ 
lar  fragment,  the  articular  surface  of  which  is 
turned  forwards  and  inwards,  with  a  slight  inclina¬ 
tion  downward,  nearly  at  right  angles  to  the  rest 
of  the  bone,  apparently  by  the  dragging  of  the 
weight  of  the  shoulder,  the  point  of  which,  with 
the  scapula,  is  rounded  forwards  (Fig.  132).  When 
the  fracture  occurs  about  the  middle  of  the  bone., 
or  at  an^"  part  on  the  sternal  side  of  the  scapular 
ligaments.,  there  is  a  remarkable  degree  of  defor¬ 
mity,  owing  to  a  triple  displacement  of  the  ‘out¬ 
ward  fragment  inwards,  downwards,  and  slightly 
backwards,  so  far  as  the  inner  extremity  is  con¬ 
cerned,  but  the  outer  end  is  rotated  forwards.  This  displacement  is 
owing  to  two  causes,  one  of  which  is  mechanical  and  the  other  muscular. 
The  displacement  downwards  is  owing  to  the  weight  of  the  arm  dragging 
the  fragment  down.  The  displacement  inwards,  with  the  rotation  of  the 
shoulder  forwards  and  pointing  of  the  sternal  end  of  the  outer  fragment 
backwards,  is  due  to  the  action  of  the  muscles  that  pass  from  the  trunk 
to  the  shoulder  drawing  the  scapula  and  the  whole  of  the  upper  extremity 
forwards  and  inwards  towards  the  mesial  line,  when  the  support  of  the 
clavicle  is  removed.  The  outer  extremity  of  the  inner  fragment  appears 
to  be  elevated,  the  skin  being  drawn  tensely’’  over  it ;  but  this  is  rather 
owing  to  the  depression  of  the  outer  portion  of  the  bone  ;  it  is  in  reality 


Fig.  131. 


Fig.  133. 


Fracture  of  Clavicle,  outside 
of  Trapezoid  Ligament. 


348 


SPECIAL  FRACTURES. 


kept  fixed  by  the  antagonism  between  the  sterno-cleido-mastoid  and  great 
pectoral  muscles.  On  looking  at  a  patient  with  fracture  of  the  clavicle 
in  this  situation,  the  nature  of  the  injury  is  at  once  evident.  The  flat¬ 
tening  of  the  shoulder,  with  its  point  approximated  towards  the  sternum; 
the  great  prominence  formed  by  the  inner  end  of  the  fragment,  over 
which  the  skin  is  tightly  stretched ;  the  sudden  depression  under  this, 
and  the  crepitus,  which  can  be  easil}^  induced  by  raising  and  rotating 
the  shoulder  at  the  same  time  that  the  elbow  is  pressed  to  the  side, 
indicate  in  the  most  unequivocal  manner  the  nature  of  the  injuiy.  The 
attitude  of  the  patient  is  remarkable ;  he  sits,  leaning  his  head  down  to 
the  affected  side,  so  as  to  relax  the  muscles,  and  supports  his  elbow  and 
forearm  in  the  sound  hand,  in  order  to  take  off  the  weight  of  the  limb. 

When  the  fracture  occurs  near  to  the  sternal  end  of  the  bone,  it  is 
usually,  if  not  always,  transverse.  If  it  occur  internally  to  the  rhom¬ 
boid  ligament,  the  outer  fragment  is  displaced  forward,  but  remains  in 
the  same  horizontal  level  as  the  sternal  fragment.  If  the  triple  displace¬ 
ment  of  the  outer  fragment,  characteristic  of  fractured  clavicle,  viz.,  in 
a  direction  downwards,  forwards,  and  inwards,  have  occurred,  then  R. 
W.  Smith  believes  that,  however  near  the  joint  the  fracture  may  appear 
to  be,  it  must  in  reality  have  occurred  externally  to  the  costo-clavicular 
ligament,  which  is  too  strong  to  admit  of  this  displacement,  or  to  be 
ruptured,  and  so  to  allow  it  to  be  occasioned. 

Comminuted  Fracture  of  the  Clavicle  from  direct  violence  is  often  a 
serious  accident,  as  the  subclavian  vein  and  subjacent  plexus  of  nerves, 
or  the  upper  part  of  the  pleura,  may  be  seriously  injured.  In  a  case  of 
this  kind  that  was  under  my  care  some  time  since,  the  subclavian  vein 
was  apparently  wounded,  great  extravasation  of  blood  taking  place  about 
the  shoulder  and  neck,  and  the  circulation  through  the  veins  of  the  arm 
being  so  much  interfered  with  as  to  threaten  gangrene.  The  case,  how¬ 
ever,  did  perfectly  well  under  the  continuous  application  of  arnica  lotions 
to  the  shoulder,  and  attention  to  the  position  of  the  arm. 

Treatment. — There  are  few  fractures  for  the  cure  of  which  so  great  a 
variety  of  ingenious  and  complicated  contrivances  has  been  devised,  as 
those  of  the  clavicle,  and  there  are  few  in  which  so  much  ingenuity  has 
been  displayed  in  vain  ;  for,  however  perfect  the  apparatus  may  appear 
to  be,  it  seldom  answers  the  purpose  in  view,  viz.,  to  cure  the  fracture 
without  deformity.  I  believe  that  more  may  be  done  with  a  little  skill 
and  patience  by  simple  means,  than  by  the  most  elaborate  mechanical 
contrivances. 

When  the  fracture  occurs  at  the  tip  of  the  acromial  end  of  the  clavicle, 
there  is  little  if  any  linear  displacement  of  the  broken  bone ;  and  a 
figure-of-8  bandage  round  the  shoulders,  and  keeping  the  arm  in  a  sling, 
will  prevent  the  tendency  to  rotation  of  the  shoulder  forwards.  When 
the  bone  is  broken  underneath  the  scapulo-clavicular  ligaments,  there  is 
but  little  displacement,  and  the  same  treatment  will  suffice. 

But  when  the  fracture  is  situated  towards  the  middle  of  the  bone,  or 
indeed  at  any  point  to  the  inside  of  these  ligaments,  then  the  manage¬ 
ment  is  more  difficult;  and  there  are  three  principal  indications  to  be 
attended  to  in  order  to  correct  the  triple  displacement  of  the  scapular 
fragment. 

1.  By  making  a  fulcrum  of  a  thick  wedge-shaped  cushion  with  its 
broad  end  upwards  in  the  axilla,  and  then  bringing  the  elbow  closely  to 
tlie  side,  the  humerus  is  made  to  act  as  a  lever  and  draw  the  shoulder 
and  the  scapular  fragment  outwards,  thus  correcting  the  displacement 
inwards.  2.  By  pressing  the  elbow  well  backwards,  behind  the  lateral 


FRACTTTRES  OF  THE  SCAPULA. 


349 


median  line  of  the  bod}’,  the  tendency  to  rotation  forwards  of  the 
shoulder  is  removed.  3.  By  elevating  the  shoulder,  and  taking  off  the 
weight  of  the  arm  by  means  of  a  short  sling  that  passes  well  under 
the  elbow,  the  displacement  downwards  is  remedied.  By  these  simple 
means  the  triple  displacement  of  the  outer  fragment  is  corrected.  But 
the  great  diflSculty  consists  in  keeping  the  fracture  in  a  good  position; 
and  when  it  is  oblique,  this  becomes  almost  impossible,  so  that  a  cure 
without  nodular  or  angular  deformity  is  very  seldom  obtained. 

In  applying  the  necessary  apparatus,  care  must  be  taken  to  bandage 
the  fingers  separately,  to  pad  the  palm  of  the  hand  with  cotton-wadding, 
and  to  apply  a  roller  up  the  arm  as  high  as  the  axillary  pad.  Before 
applying  the  roller,  the  elbow  must  always  be  flexed;  otherwise  undue 
and  dangerous  constriction  of  the  arm  may  occur.  The  pad  should  be 
firm,  made  of  bed-tick  stuffed  with  bran,  six  inches  long,  five  broad,  and 
three  thick  at  its  upper  part ;  the  sling  must  support  the  elbow,  and  the 
hand  should  be  well  raised  across  the  chest. 

In  the  accompan3’ing  figure,  the  sling  does  not 
extend  so  far  toward  the  elbow  as  it  ought  to. 

It  is  represented  in  this  wa}’,  in  order  not  to 
conceal  the  other  parts  of  the  apparatus  (Fig. 

133). 

The  elbow  must  be  kept  to  the  side  b}"  a  few 
turns  of  a  roller,  or  by  means  of  a  padded  belt. 

In  children,  in  whom  these  fractures  often  oc¬ 
cur,  there  is  frequently  a  difficult}’  in  keeping 
the  bandages  properly  applied;  in  these  circum¬ 
stances  the  starched  apparatus  will  be  found 
very  useful,  care  being  taken  to  reapply  it  as 
often  as  it  becomes  loose,  lest  deformity  re¬ 
sult.  Fractured  clavicles  occurring  in  females, 
to  whom  any  irregularity  of  union  in  this  situ¬ 
ation  would  be  very  annoying,  are  best  treated 
by  keeping  the  patient  in  bed  for  the  first  two 
or  three  weeks.  By  this  plan,  which  is  as  old 
as  the  days  of  Hippocrates,  I  have  seen  better  results  produced  than  by 
any  other.  The  limb  should  be  put  up  as  represented  in  Fig.  133. 

When  both  clavicles  are  broken,  the  patient  should  be  kept  in  bed,  and 
the  shoulder  fixed  and  drawn  backwards  by  means  of  a  figure-of-8-band- 
age.  In  the  case  already  alluded  to  (p.  3IT),  this  could  not  be  borne, 
owing  to  the  simultaneous  fracture  of  the  ribs;  but  the  patient  never¬ 
theless  made  a  good  recovery  with  little  deformity. 

Fractures  of  the  Scapula. — 1.  Fracture  of  the  Body  of  the  Sca¬ 
pula  is  not  very  commonly  met  with ;  and  when  it  occurs,  being  always 
the  result  of  considerable  direct  violence,  it  is  usually  associated  with 
serious  injury  to  the  subjacent  ribs  and  trunk.  The  thick  layer  of 
muscles  overlying  this  bone  not  only  protects  it,  but  prevents  displace¬ 
ment,  and  renders  the  detection  of  its  fracture  diflicult.  The  fracture 
usually  takes  place  across  the  bone,  immediately  below  the  spine ;  but 
occasionally  it  may  be  split  longitudinally  or  starred. 

The  Treatment  consists  in  placing  the  arm  in  a  sling,  the  application 
of  a  body-bandage,  and  support  of  the  part  with  a  pad.  But  all  Sur¬ 
geons  who  have  seen  this  accident  are  agreed  as  to  the  extreme  difficulty 
of  obtaining  union  without  considerable  deformity;  which,  however,  is 
of  less  moment  here  than  in  most  other  situations. 


Apparatus  for  Fractured 
Clavicle. 


850 


SPECIAL  FKACTURES. 


Fractures  in  the  Vicinity  of  the  Shoulder- Joint  are  of  common  occur¬ 
rence,  and  may  happen  either  in  the  bony  points  of  the  scapula  that 
overhang  this  articulation,  or  else  in  the  upper  end  of  the  humerus. 
Not  unfrequently  there  is  double  fracture  in  the  neighborhood  of  this 
articulation ;  thus  the  acromion  may  be  broken,  as  well  as  the  neck  of 
the  humerus.  These  complications,  as  well  as,  in  many  cases,  the 
amount  of  contusion,  and  the  rapid  swelling  that  takes  place,  necessarily 
renders  the  diagnosis  somewhat  difficult. 

2.  The  Acromion^  forming  as  it  does  the  very  tip  of  the  shoulder,  is 
more  frequently  broken  than  any  other  part  of  the  scapula.  But,  in 
spite  of  its  exposed  situation,  fracture  of  this  process  through  its  base 
is  not  very  common ;  at  least  I  have  seen  but  few  cases  of  it,  and  there 
is  good  reason  to  believe  that  many  of  the  cases  of  supposed  fracture  in 
this  situation  are  in  reality  cases  of  delayed  ossification  of  the  line  of 
junction  between  the  base  and  the  epiph3^sis.  Notwithstanding  this 
source  of  fallacjq  there  can  be  no  doubt,  as  is  proved  by  numerous 
preparations,  that  this  fracture  does  occur. 

The  Signs  of  this  fracture  are  obvious.  When  the  acromion  is  broken 
off'  near  its  root,  the  arm  hangs  as  a  dead  weight  b^'  the  side,  and  the 
patient,  feeling  as  if  his  arm  were  dropping  off,  supports  it  with  the 
other  hand.  There  is  flattening  of  the  shoulder,  which  is  most  marked 
when  the  patient  is  looked  at  from  behind  ;  and  the  head  of  the  humerus 
can  be  felt  somewhat  lower  in  the  axilla  than  natural.  On  running  the 
finger  along  the  spine  of  the  scapula,  a  sudden  inequality  in  the  line  of 
the  bone  can  be  detected;  and,  on  raising  the  elbow  and  rotating  the 
arm,  crepitus  can  be  felt,  the  rounded  outline  of  the  shoulder  being 
restored. 

When  the  tip  onl}"  of  the  acromion  is  broken  off,  the  nature  of  the 
injiiiy  may  be  suspected  if  the  patient  be  unable  to  raise  his  arm  to  a 
level  with  his  head,  so  as  to  touch  the  crown,  owing  to  some  of  the 
fibres  of  the  deltoid  having  lost  their  points  of  attachment;  and  it  may 
be  determined  ly  the  existence  in  a  minor  degree  of  some  of  the  pre¬ 
ceding  signs,  which  prevent  the  accident  from  being  confounded  with 
imral3’sis  of  the  deltoid  from  contusion;  and  especiall3^  1)3^  the  tip  being 
felt  to  be  detached.  But,  as  has  already  been  stated,  this  ma3^  be  a 
congenital  defect,  to  which  perhaps,  attention  has  only  been  directed 
when  the  shoulder  has  been  bruised  or  otherwise  injured. 

The  Treatment  consists  principall3"  in  raising  the  elbow,  so  as  to  take 
off  the  weight  of  the  limb,  and  to  push  up  the  acromion  by  the  head  of 
the  humerus.  If  the  extremity  only  be  broken  off  in  front  of  the 
acromio-clavicular  articulation,  a  pad  ma3"  be  placed  between  the  elbow 
and  the  side,  in  order  to  direct  the  arm  somewhat  upwards  and  inwards, 
and  the  limb  must  be  fixed  in  this  position  by  a  bandage  and  sling. 
Should  the  fracture  have  taken  place  at  or  behind  the  line  of  the  clavi¬ 
cular  articulation,  the  treatment  must  be  the  same  as  that  for  fractured 
clavicle. 

When  the  base  of  this  process  is  broken  across,  there  is  not  much 
separation  between  the  fragments,  and  union  usually  takes  place  by 
bone.  When  the  apex  is  detached,  fibroid  or  ligamentous  union  gener- 
all3^  occurs,  the  fragments  being  widel3^  separated. 

3.  The  Coracoid  Process  is  but  seldom  broken,  there  not  being  more 
than  ten  or  twelve  unequivocal  cases  of  this  accident  recorded.  It  cannot 
happen,  except  b3^  very  direct  violence.  There  is  in  the  Museum  of 
Universit3"  College  a  preparation  showing  a  fracture  of  the  base  of  this 
process,  implicating  and  extending  through  the  glenoid  cavit3q  and 


FRACTURES  OF  THE  HUMERUS. 


351 


complicated  with  fracture  across  the  base  of  the  acromion.  The  attach¬ 
ment  of  such  powerful  muscles  as  the  pectoralis  minor,  biceps,  and 
coraco-brachialis,  displaces  the  fragment  considerably,  and  would  do  so 
still  more,  were  it  not  that  it  is  kept  in  position  b}'  the  ligaments  to 
which  it  gives  insertion,  and  whose  fibres  are  expanded  over  it. 

The  only  Treatment  that  can  be  adopted  is  to  put  the  arm  in  a  sling 
and  fix  it  to  the  side. 

4.  Fracture  of  the  Nech  of  the  Scapula  immediately^  behind  the  glenoid 
cavity  is  a  rare  injuiy.  Its  existence  has  been  doubted  :  A.  Cooper  and 
South  have  stated  that  cases  so  described  are,  in  reality^,  instances  of 
fracture  of  the  upper  end  of  the  humerus.  There  is,  according  to  South, 
no  preparation  in  any”  museum  in  London  illustrating  fracture  of  the 
neck  of  the  scapula.  A  case,  however,  recorded  by  Spence  in  the  Edin¬ 
burgh  Medical  Journal  for  18G3,  puts  the  occasional  occurrence  of  the 
injuiy  bey”ond  doubt.  A  man  was  brought  into  the  Edinburgh  Infirmary”, 
who  had  fallen  on  his  shoulder  while  intoxicated.  There  was  falling  of 
the  limb  towards  the  axilla,  with  projection  of  the  acromion  and  flatten¬ 
ing  of  the  deltoid ;  and  crepitus  was  felt.  The  contour  of  the  shoulder 
was  restored  by”  drawing  the  arm  from  the  side  and  raising  the  limb. 
The  man  died  some  days  afterwards  from  meningitis,  the  result  of  an 
injuiy  to  the  forehead  which  he  had  received  during  the  fall.  On  ex¬ 
amining  the  shoulder,  “  the  fracture  was  found  to  pass  obliqely”  from 
below,  upwards  and  forwards,  commencing  about  half  an  inch  behind  the 
origin  of  the  long  head  of  the  biceps,  and  separating  the  neck  and  four- 
fifths  of  the  lower  part  of  the  glenoid  cavity”  from  the  scapula.  The  long 
head  of  the  biceps,  and  the  whole  of  the  glenoid  ligament  had  also  been 
torn  from  the  upper  fragment  of  the  glenoid  cavity,  and  carried  along 
with  the  displaced  portion.” 

The  Treatment  of  such  an  injury”,  if  it  were  diagnosed,  would  consist 
in  keeping  the  whole  arm  well  raised  and  fixed  to  the  chest,  with  a  pad 
in  the  axilla. 

Fractures  of  the  Humerus. — In  studving  the  fractures  of  the 
humerus  we  must  divide  that  bone  into  three  parts,  the  Upper  Articular 
End,  the  Shaft,  and  the  Lower  Articular  End. 

1.  Fracture  of  the  Upi^er  Articular  End  of  the  humerus  not  unfre- 
,  quently”  occurs,  constituting  an  important  class  of  injuries  which  have 
been  carefully”  studied  by  Sir  A.  Cooper,  and  more  recently”  by'  R.  W. 
Smith,  whose  work  on  Fractures  deserves  the  attentive  perusal  of  every 
practitioner. 

Five  kinds  of  fracture  of  the  humerus  are  met  with  in  the  immediate 
vicinity  of  the  shoulder-joint.  Two  of  these  are  Intracapsular,  viz.. 
Simple  Fracture  of  the  Anatomical  Xeck,and  Impacted  Fracture  of  this 
portion  of  the  bone.  The  remaining  three  are  Extracapsular^  viz.. 
Fractures  of  the  Surgical  Xeck — Simple  and  Impacted;  and  Separation 
of  the  Great  Tubercle. 

Intracapsular  Fracture  of  the  Neck  of  the  Humerus. — When  the 
fracture  occurs  at  the  anatomical  neck.,  the  head  of  the  bone  is  detached 
from  the  tubercles,  a  little  above  or  at  the  line  of  insertion  of  the  cap¬ 
sule.  This  fracture  is  occasioned  by  severe  falls  or  blows  on  the  shoul¬ 
der.  It  cannot  result  from  indirect  violence.  A  fall  on  the  hand  or 
elbow  may”  dislocate  the  humerus  or  fracture  its  shaft,  but  it  cannot 
break  its  upper  articular  end.  This  fracture  is  comparatively'  rare  in 
children,  but  is  frequent  in  adults. 

The  signs  of  this  injury  are  by  no  means  very^  distinct,  though  much 
light  has  been  thrown  upon  them  by”  the  labors  of  R.  W.  Smith.  There 


352 


SPECIAL  FRACTURES. 


is  loss  of  motion  in  the  shoulder,  with  some  swelling  and  considerable 
pain,  together  with  some  deformity ;  an  irregularity,  produced  by  the 
upper  end  of  the  lower  fragment,  can  be  felt  towards  the  inner  side  of 
the  joint ;  crepitus  is  easily  produced  ;  and  there  is  a  measurement  from 
the  acromion  to  the  olecranon,  shortening  to  the  extent  of  about  one- 
third  of  an  inch. 

When  this  fracture  is  impacted^  the  upper  fragment  penetrates  the 
lower  one.  In  consequence  of  this,  the  axis  of  the  humerus  is  directed 
somewhat  inwards  towards  the  coracoid  process;  here  also  some  irregular 
osseous  swelling  may  be  detected.  The  head  of  the  bone  can  be  felt  in 
the  glenoid  cavity,  but  is  not  in  the  axis  of  the  limb,  the  elbow  projecting 
slightly  from  the  side,  there  being  at  the  same  time  a  hollow  some  little 
distance  under  the  acromion.  There  is  consequently  more  deformity 
about  the  joint  in  the  impacted  than  in  the  simple  intracapsular  fracture, 
with  the  same  impairment  of  motion,  but  only  slight  crepitus  on  firmly 
grasping  the  shoulder  and  rotating  the  elbow. 

In  fracture  of  the  anatomical  neck  of  the  humerus,  the  portion  of  bone 
broken  off  is  truly  a  foreign  body  in  the  joint,  and,  being  unconnected 
with  any  ligamentous  structure,  may  perish  and  thus  give  rise  to 
destruction  of  the  articulation.  When  this  does  not  take  place,  it  is 
probable  that  impaction  of  the  fragment  has  occurred,  and  that  thus  its 
life  is  maintained  ;  or  it  may  happen,  as  K.  W.  Smith  supposes,  that  its 
vitality  is  occasionally  preserved  in  consequence  of  some  partial  union 
being  kept  up  between  it  and  the  rest  of  the  bone  b}^  untorn  shreds  of 
capsule.  In  either  case,  the  principal  reparative  efforts  are  made  by  the 
lower  fragment,  which  deposits  callus  abundantly. 

Treatment. — As  there  is  often  much  swelling  from  contusion  in  these 
cases,  evaporating  lotions  should  be  had  recourse  to  for  a  few  days.  A 
pad  may  then  be  placed  in  the  axilla,  and  a  leather  or  gutta-percha  cap 
fitted  to  the  shoulder  and  upper  arm,  the  limb  having  previously  been 
bandaged.  The  hand  must  be  supported  in  a  sling,  and  the  elbow  fixed 
to  the  side.  In  examining  and  reducing  these  intracapsular  fractures, 
no  violence  should  be  employed,  lest  the  impaction  of  the  fragment  be 
disturbed,  or  portions  of  untorn  capsule,  on  which  the  ultimate  osseous 
repair  of  the  injury  is  dependent,  be  broken  through. 

Extracapsular  Fracture  of  the  Neck  of  the  Humerus. — In  this  injury, 
the  bone  is  broken  through  the  surgical  neck.,  or  that  portion  which  is 
below  the  tubercles,  but  above  the  insertions  of  the  pectoralis  major, 
latissimus  dorsi,  teres  major,  and  deltoid  muscles.  This  accident  is  most 
frequent  in  adults,  but  it  may  occur  in  children  as  well,  the  separation 
taking  place  through  the  line  of  junction  between  the  epiphysis  and  the 
shaft  of  the  bone.  In  this  fracture  there  is  double  displacement ;  the 
head  of  the  bone  and  upper  fragment  are  rotated  outwards  and  abducted, 
being  under  the  influence  of  the  muscles  inserted  into  the  great  tubercle, 
whilst  the  shaft  is  drawn  upwards  and  inwards  and  forwards  under  the 
coracoid  process,  by  the  muscles  going  from  the  trunk  to  the  arm,  and 
by  the  flexors  of  the  limb. 

The  Signs  of  this  Tracture  are  sufficiently  obvious.  The  glenoid 
cavity  is  filled  by  the  head  of  the  bone,  which  can  be  felt  in  it.  Below 
this  there  is  a  depression  ;  crepitus  is  easily  produced,  and  there  are 
great  mobility  of  the  lower  fragment,  and  shortening  of  the  limb  to  the 
extent  of  from  three-quarters  to  one  inch ;  but  the  most  remarkable  sign 
is  the  prominence  formed  by  the  upper  end  of  the  shaft  of  the  humerus, 
which  projects  under  the  integuments,  and  can  readily  be  felt  under  the 
coracoid  process,  especially  when  the  elbow  is  pushed  upwards  and  rotated. 


FRACTURES  OF  THE  NECK  OF  THE  HUMERUS. 


353 


The  axis  of  the  bone  is  also  directed  obliquely  upwards  and  inwards 
towards  this  point.  In  consequence  of  the  irritation  of  tlie  nerves  of 
the  axillary  plexus  b}^  tliis  fragment,  which  is  often  very  sharp  and 
angular,  a  good  deal  of  pain  is  complained  of  in  the  arm  and  fingers. 
This  sign,  however,  is  not  met  with  in  children,  owing  to  the  greater 
smoothness  of  the  fractured  surfaces. 

Impacted  Exlracapmlar  Fracture  of  the  Neck  of  the  Humerus  has 
been  especially  treated  by  R.  AY.  Smith  in  his  excellent  work  on  Fractures. 
In  this  injuiy,  the  superior  fragment  being  penetrated  b}'  the  inferior  one, 
the  continuit}^  of  the  bone  and  its  firmness  are  in  a  great  measure  pre¬ 
served  ;  hence,  the  usual  signs  of  fracture,  such  as  mobility,  dis})lacement, 
and  crepitus,  are  not  readil}^  obtainable,  and  indeed  the  signs  of  this 
injury  are  chiefl}'  negative.  Thus,  there  are  impairment  of  motion,  slight 
deformity  about  the  joint  and  upper  part  of  the  arm,  and  some  crepitus  ; 
but  the  latter  is  only  obtainable  with  difficulty,  and  by  firmly  grasping 
the  head  of  the  bone  whilst  the  elbow  is  being  rotated. 

O 


Fig.  134. 


The  Treatment  to  be  adopted  in  these  cases  should  be  carried  out  in 
accordance  with  the  following  principles  and  details  :  1.  To  bandage  the 
fingers,  hand,  and  arm  so  as  to  prevent  con¬ 
gestion  and  oedema  of  the  limb;  2.  To  place 
a  pad  in  the  axilla  to  act  as  a  fulcrum  ;  3.  To 
bandage  the  elbow"  closely  to  the  side  so  as  to 
overcome  the  displacement  inwards  of  the 
upper  end  of  the  shaft,  which  will  be  thrown 
outwards  by  the  axillary  pad  ;  4.  To  carry  the 
elbow  (whilst  it  is  being  bandaged  to  the  side) 
forwards  across  the  chest,  in  advance  of  the 
lateral  median  line,  in  order  to  counteract  the 
forward  displacement  of  the  upper  end  of  the 
shaft,  and  thus  to  throw  it  backwards  towards 
the  head  of  the  humerus;  5.  To  apply  a  sling 
so  as  merel}^  to  support  the  hand  and  wrist, 
allowing  the  elbow  to  hang  unsupported,  and 
thus  letting  the  weight  of  the  arm  counteract 
the  displacement  upwards  (Fig.  134).  By 
these  means  the  triple  displacement  of  the 
upper  end  of  the  shaft  outwards,  forwards, 
and  upwards  will  be  counteracted.  The  whole 
is  then  to  be  steadied  by  means  of  a  leather 

or  gutta-percha  cap,  carefully  moulded  and  fitted  to  the  shoulder  and 
arm.  As  the  bruising  and  extravasation  are  often  very  considerable  in 
these  cases,  it  is  as  well  to  apply  evaporating  lotions  in  the  first  instance. 

Ill  the  management  of  some  of  these  fractures,  I  have  found  a  very 
convenient  apparatus  to  consist  of  a  leather  splint  about  two 
feet  long  by’’  six  inches  broad,  bent  upon  itself  in  the  middle, 
so  that  one-half  of  it  may  be  applied  lengthwise  to  the  chest, 
and  the  other  half  to  the  inside  of  the  injured  arm;  the  angle 
formed  by  the  bend,  which  should  be  somewhat  obtuse,  being 
w’ell  pressed  up  into  the  axilla.  In  this  way  the  limb  is  steadied, 
and  the  tendency  to  displacement  inwards  of  the  lower  fragment 
is  corrected. 

In  some  cases,  fracture  of  the  neck  of  the  humerus  is  followed  by 
atrophy  of  the  bone,  though  good  union  has  taken  place. 

Compound  Fracture  of  the  Surgical  Neck  of  the  Humerus  is  not  of 
common  occurrence.  I  have  had  a  case  under  my  care  in  which  the 


Apparatus  for  Fracture  of  the  Neck 
of  the  Humerus. 


r\ 


VOL.  I. — 23 


354 


SPECIAL  FEACTURES. 


accident  happened  to  a  lad  from  a  fall  out  of  a  window.  The  fracture 
was  transverse,  and  the  upper  extremity  of  the  low'er  fragment  was 
driven  upwards,  and  protruded  through  the  deltoid,  to  the  extent  of  an 
inch  and  a  half.  It  was  reduced  with  difficulty:  as  great  irritation  set 
up  around  the  seat  of  injury,  and  as  there  was  a  tendency  to  recurrent 
protrusion  of  the  upper  extremity  of  the  lower  fragment,  this  was  turned 
out  by  enlarging  tlie  wound,  and  about  an  inch  and  a  half  of  it  sawn  off. 
Union  took  place  between  the  fragments,  and  recovery  was  effected  with 
a  very  useful  arm. 

Sepai'ation  of  the  Great  Tubercle  of  the  Humerus  occasionally  occurs 
from  falls  and  blows  upon  the  shoulder;  but  more  commonly  as  the 
result  of  the  violent  action  of  the  three  external  rotator  muscles  which 
are  inserted  into  it.  In  this  injury  there  is  a  double  displacement ;  the 
tubercle  is  carried  upwards  and  outwards  away  from  the  head  of  the 
bone,  and  under  and  external  to  the  acromion  process:  the  head  is 
drawn  upw^ards  and  inwards  by  the  muscles  passing  from  the  trunk  to 
the  arm,  as  well  as  b}^  the  flexors  of  the  arm,  in  such  a  way  that  it  lies 
upon  the  inner  edge  of  tlie  glenoid  cavity  under  the  coracoid  process, 
and  is  indeed  almost  luxated.  The  consequence  of  this  double  displace¬ 
ment  is  a  great  increase  in  the  breadth  of  the  shoulder,  which  has  nearly 
double  its  natural  size;  on  examination,  a  rounded  tumor — the  head  of 
the  bone — movable  on  rotating  the  arm,  can  be  felt  under  the  coracoid 
process,  whilst  another  osseous  mass — the  great  tubercle — may  be  felt 
at  the  outer  and  back  part  of  the  joint ;  between  these  a  sulcus  is  per¬ 
ceptible,  and  crepitus  ma}^  be  felt  by  bringing  the  two  portions  of  bone 
into  apposition  and  rotating  the  arm.  This  accident,  which  is  rare,  has 
been  most  carefully  described  by  Guthrie  and  Smith,  to  whom  our 
knowledge  of  its  pathology  is  due. 

The  Treatment  consists  in  an  attempt  to  bring  the  detached  tubercle 
into  contact  with  the  head  of  the  bone,  and  retain  it  there;  this  may  be 
done  either  b}'^  mechanical  means,  or  by  relaxation  of  the  muscles.  The 
treatment  by  mechanical  means  consists  in  placing  a  pad  in  the  axilla, 
and  bringing  the  elbow  to  the  side  so  as  to  throw  out  the  head  of  the 
bone,  at  the  same  time  that,  by  means  of  a  compress,  the  tubercle  is 
pressed  into  proper  position,  the  arm  being  supported  in  a  sling.  The 
treatment  by  relaxation  of  tlie  muscles  consists  in  elevating  and  extending 
the  arm  from  the  trunk;  in  carrying  this  out,  it  is  necessary  that  the 
patient  be  confined  to  bed,  the  arm  being  supported  on  a  pillow. 

Compound  and  Comminuted  Fractures  of  the  Head  of  the  Humerus 
can  only  occur  as  a  consequence  of  gunshot  injury.  In  these  cases  there 
may  also  be  splintering  of  the  acromion  or  coracoid  processes,  of  the 
neck  of  the  scapula  or  glenoid  cavit3q  and  possibly  injuiy  to  the  axillaiy 
vessels  and  plexus  of  nerves. 

The  Treatment  must  depend  upon  the  extent  of  the  complications.  If 
the  injuiy  be  chiefly  confined  to  the  head  of  the  humerus,  with  little 
damage  to  the  soft  [larts,  and  none  to  the  main  vessels  or  nerves,  excision 
should  be  practised,  aiy  splinters  in  connection  with  the  scapular  pro¬ 
cesses  being  removed  at  the  same  time.  Should,  however,  the  soft  parts 
be  extensive!}^  disorganized,  and  especially  the  great  vessels  and  nerves 
torn,  amputation  is  the  sole  resource. 

2.  Fractures  of  the  Shaft  of  the  Humerus  are  usually  somewhat  oblique 
from  above,  downwards,  and  outwards.  The}^  may  occur  from  any  kind 
of  external  violence,  but  are  more  frequently  the  result  of  muscular 
action  than  those  of  aiy^  other  bone.  The  nature  of  the  accident  can 
be  at  once  detected  by  the  great  mobility  of  the  fragment,  the  ready 


FRACTURES  OF  THE  HUMERUS. 


355 


production  of  crepitus,  and  the  other  ordinary  signs  of  fracture.  The 
direction  of  the  displacement  depends  upon  the  seat  of  the  fracture.  If 
the  bone  be  broken  above  the  insertion  of  the  deltoid,  and  below  those 
of  the  pectoralis  major,  latissimus  dorsi,  and  teres  major,  the  lower 
fragment  will  lie  to  the  outer  side  of  the  upper.  If  the  fracture  be  below 
the  insertion  of  the  deltoid,  the  upper  fragment  will  be  abducted  by  that 
muscle,  and  the  lower  will  be  to  its  inner  side. 

I'he  Treatment  is  of  the  simplest  character;  flexing  the  elbow,  band¬ 
aging  the  arm,  and  the  application  of  two  or  three  well-padded  splints, 
the  inner  one  of  which  should  be  rectangular,  being  all  that  is  necessaiy. 
In  applying  a  splint  to  the  inner  side  of  the  arm,  care  must  be  taken  that 
it  do  not  press  upon  the  axillary  vein,  lest  oedema  of  the  limb  occur. 

3.  Fractures  in  the  Vicinity  of  the  Elbow- Joint  may  occur  through  any 
of  the  osseous  prominences  in  this  situation.  They  are  very  commonly 
complicated  with  dislocation,  with  severe  contusion  and  injuiy  of  the 
joint,  or  perhaps  with  comminution  of  the  bones,  and  considerable  lacera¬ 
tion  of  the  soft  parts  covering  them.  In  most  cases  swelling  speedily 
comes  on,  tending  to  obscure  materially  the  natui’e  of  the  injuiy.  They 
maybe  classified  as — Separation  of  the  Lower  Epiph3’sis  of  the  Humerus; 
Transverse  Fracture  of  the  Lower  End  of  the  Bone;  Fracture  of  either 
Condyle  ;  and  to  these  ma^"  be  added  Fracture  of  the  Olecranon. 

Separation  of  the  Loiuer  Epiphysis  of  the  Humerus  in  children,  before 
its  ossification  is  complete,  is  ly  no  means  an  unfrequent  accident ;  the 
fragment  being  carried  backwards,  with  the  bones  of  the  forearm  con¬ 
nected  with  it,  so  as  to  cause  considerable  displacement  posteriorh^  In 
this  accident  the  trochlea,  the  capitellum,  and  the  condyles,  are  broken 
off' from  the  shaft,  which  remains  zn  situ.  It  is  the  detached  articular 
end  of  the  bone  that  is  carried  backwards  with  the  forearm.  The  de¬ 
tached  fragment  may  readil\^  be  replaced;  but,  as  soon  as  it  it  is  left  to 
itself,  it  again  slips  out  of  its  position.  As  this  happens  without  crepitus, 
owing  to  the  fracture  being  between  cartilaginous  surfaces,  the  injuiy  is 
apt  to  be  mistaken  for  dislocation  of  the  forearm  backwards. 

Transverse  Fracture  of  the  Lower  End  of  the  just  above  the 

cond3des,  occasion all3''  occurs  in  adults.  The  displacement  backwards 
of  the  forearm  and  lower  fragment,  the  pain,  and  crepitus,  indicate  the 
nature  of  the  accident. 

Fracture  of  either  Condyle  of  the  Humerus  ma3^  arise  from  blows  and 
falls  on  the  elbow.  There  is  considerable  pain  about  the  seat  of  the 
injuiy,  but  usually  not  much  displacement;  un¬ 
less,  as  in  Fig.  135,  there  be  a  transverse  fracture 
of  both  cond3des.  Crepitus,  however,  ma3’’  readil3^ 
be  felt  by  rotating  the  radius,  if  it  be  the  external 
cond3de  that  is  injured  ;  or  b3"  flexing  and  pronat- 
ing  the  forearm,  if  it  be  the  internal  condyle  that 
has  been  detached. 

The  Treatment  of  all  these  injuries  must  be 
conducted  on  very  similar  principles.  The  swell¬ 
ing  and  inflammatory  action,  which  rapidl3'  super¬ 
vene,  usualh'  require  local  anti-inflammatoiy  treat¬ 
ment,  and  the  application  of  cold  lotions,  or  of 
irrigation;  the  arm  being  flexed,  and  supported 
in  an  eas3’-  position  on  a  proper  splint.  After  the 

subsidence  of  the  swelling,  the  fractured  bone,  Traa,ve,-«  Fract«,e  of  hu- 
whatever  be  the  precise  nature  of  the  injury,  is  merus.  Separation  of  Con- 
best  maintained  in  position  b3'  being  put  up  in  dyies. 


Fis:,  135. 


356 


SPECIAL  FEACTURES. 


Fig.  136. 


angular  splints;  the  forearm  being  kept  in  the  mid-state  between  prona¬ 
tion  and  supination,  and  well  supported  in  a  sling.  It  is  in  these  par¬ 
ticular  fractures  that  passive  motion,  if  it  ever  be  emplo3’ed,  ma^’  be  had 
recourse  to,  a  tendenc}’  to  rigidity  of  the  joint  being  otherwise  often  left. 
The  motion  should  be  begun  in  adults  at  the  expiration  of  a  month  or 
five  weeks;  in  children,  at  the  end  of  three  or  four  weeks  after  the  occur¬ 
rence  of  the  accident.  Union  iisuallv  takes  place  readily.  I  have,  how¬ 
ever,  seen  one  instance  of  an  un united  fracture  of  the  external  cond^de 
of  the  humerus  in  a  boy  about  ten  3’ears  old. 

Injury  of  Nerves  in  Fracture  o  f  the  Humerus _ In  simple  fracture  of 

the  shaft  of  the  humerus,  it  ma3'  happen  tliat  the  trunk  of  the  musculo- 
spiral  nerve,  where  it  winds  round  the  bone  in  a  flat  groove,  may  be  so 
seriousl3’  implicated,  either  b3^  the  fracture  itself  or  in  the  subsequent 
formation  of  callus,  as  to  occasion  its  paral3’sis.  So  also  when  the  frac¬ 
ture  is  lower  down,  and  the  external  condvle  is  broken  off,  the  posterior 
interosseous  branch  of  that  nerve  ma3'be  injured.  When  the  main  trunk 
is  paralyzed,  supination  is  imperfect,  and  extension  of  the  hand  and  fingers 
is  entirely  lost ;  the  forearm  becomes  pronated,  and  the  hand  and  fingers 

passivel3^  flaccid,  so  that  a  peculiar 
form  of  icrist-di'op  ensues ;  all  the 
muscles  supplied  b3^  the  musculo- 
spiral  nerve  becoming  paral3’zed. 
Some  degree  of  supination,  however, 
can  be  done  by  the  action  of  the 
biceps.  Although  the  extensors  of 
the  wrist  and  fingers  have  become 
paral3'zed,  3’et,  when  the  fingers  are 
flexed  into  the  palm  (Fig.  136  a), 
the3"  can  be  extended  rapidl3’’,  and 
with  some  degree  of  force,  from  the 
second  phalangeal  articulations,  as 
far  as  is  represented  in  Fig.  136  6. 

Tliis  limited  moA'ement  of  extension 
is  due  to  the  action  of  the  interossei  and  lumbricales  muscles,  which,  being 
supplied  b3'  the  ulnar  and  median  nerves,  do  not  participate  in  the  par¬ 
alysis  that  affects  all  the  long  extensors  of  the  fingers. 

When  the  posterior  interosseous  nerve  only  is  paral3’zed,  the  loss  of 
supination  and  extension  is  necessarily’  not  so  complete  as  when  the  whole 

trunk  is  affected;  these  movements  being  still  prac¬ 
ticable  to  a  limited  extent,  through  the  medium  of 
the  long  supinator  and  the  long  extensor  of  the 
wrist,  which  are  supplied  b3’  the  radical  branch. 
If  the  paral3’sis  of  the  extensors  and  supinators  be 
allowed  to  continue  for  some  time,  the  forearm  and 
hand  become  drawn  into  a  state  of  permanent  and 
tonic  flexion  and  pronation  b3’  the  tonic  contraction 
of  the  muscles  that  act  in  those  directions  (Fig. 
137). 

The  Treatment  of  this  complication  of  simple 
fracture  of  the  humerus  must  be  conducted  on  the  following  principles: 
1.  The  support  of  the  wrist,  hand,  and  fingers  in  a  hand  and  arm-splint, 
so  as  to  prevent  the  tonic  contraction  of  the  flexors  ;  2.  Placing  the 
limb  in  the  mid-state  between  pronation  and  supination ;  and  3.  The 
application  of  electricity’  (faradization)  to  the  affected  muscles.  In 
order  to  overcome  the  tonic  flexion  of  the  hand  and  fingers,  the  splint 


Paralysis  of  Hand  (Wrist-Drop)  after  Fracture 
of  Humerus. 


Fig.  137. 


Permanent  Flexure  from 
Paralysis  after  Fracture  of 
Humerus. 


COMPOUND  FRACTURES  OF  THE  ELBOW-JOINT.  357 


(Fig.  138)  may  be  employed  with 
advantage,  the  hand-piece  admit¬ 
ting  of  upward  movement,  so  as  to 
raise  the  hand  and  extend  the 
fingers  forcibly. 

In  a  case  where  the  S3’mptoras 
denoted  pressure  on  the  miisculo- 
spiral  nerve  by  one  of  the  frag¬ 
ments  or  by  the  callus,  Ollier,  of 
L^’ons,  cut  down  on  the  bone,  re¬ 
moved  a  portion  of  the  callus  by  chisel  and  mallet,  so  as  to  expose  the 
nerve,  and  excised  also  a  portion  of  bone  (apparently  of  the  lower  frag¬ 
ment),  wdiicli  was  strangulating  the  nerve.  Gradual  improv'ement  took 
place;  and,  at  the  end  of  six  and  a  half  months,  the  patient  had  regained 
considerable  power  of  extension  of  the  metacarpus. 

Compound  and  Comminuted  Fractures  of  the  Elhow-joint  are  neces- 
saril}^  serious  accidents.  The^^  are  commonly’  occasioned  b^’  falls  on  the 
point  of  the  olecranon,  which  is  the  process  of  bone  most  frequently  and 
extensivelj"  fractured.  In  some  cases  the  olecranon  escapes  injury,  whilst 
the  lower  epiph3*sis  of  the  humerus  is  splintered  into  man3^  pieces ;  and 
more  commonl3',  perhaps,  both  bones,  ulna  as  well  as  humerus,  are 
injured.  As  the  integuments  over  the  point  of  the  elbow  are  thick  and 
hard,  veiy  extensive  comminution  of  the  bones  may  occur  witli  veiy 
little  apparent  lesion  of  the  soft  parts.  When  these  fractures  are  the 
result  of  gunshot  injuiy,  the  soft  parts  ma3'  be  extensivel3' torn,  and  the 
bones  greatly  shattered.  In  the  cases  that  occur  in  civil  practice,  I  have 
seldom  seen  much  laceration  of  the  soft  parts. 

The  Treatment  of  these  important  accidents  will  necessaril3^  depend 
upon  the  amount  of  injury  done  both  to  bones  and  to  soft  parts.  If  the  . 
articulation  be  simpl3^  opened  with  little  laceration  of  the  surrounding 
soft  parts,  and  no  comminution  of  the  fractured  bone,  the  limb  may  veiy 
commonl3'  be  preserved  by  the  employment  of  rest  and  active  anti¬ 
inflammatory  treatment.  If  the  bones  be  much  shattered,  the  soft  parts  . 
not  being  seriousl3Mmplicated,  removal  of  the  splinters  and  resection  of 
the  injured  joint  will  enable  the  Surgeon  to  save  the  rest  of  the  limb. 
But  if  the  soft  parts  be  extensively  contused  and  torn,  as  well  as  the 
bones  comminuted,  amputation  qf  the  arm  maybe  required.  If  recourse 
be  not  liad  to  primaiy  resection,  abscess  ma3'  form  in  front  of  or  around 
the  joint,  with  much  constitutional  disturbance,  requiring  the  removal 
of  the  articular  osseous  extremities  in  a  few  weeks,  or  possibly  amputa¬ 
tion  of  the  limb.  When  resection  is  determined  on,  whether  as  a  primaiy 
or  as  a  secondaiy  operation,  the  question  ma3^  arise  whether  a  partial  or 
a  complete  removal  of  the  articulation  should  be  practised.  In  these 
cases,  I  am  decidedl3'^  in  favor  of  complete  resection  ;  any  articular  sur¬ 
face  that  is  left  covered  with  an  incrusting  cartilage,  interferes  very 
materiall3^  with  the  deposit  of  Wmph  necessary  for  reparative  action. 
Before  this  can  take  place,  the  cartilage  must  be  removed  a  process 
of  disintegration,  or  necrosis  of  a  tedious  character,  and  attended  by 
profuse  suppuration.  All  this  is  avoided  by  the  complete  resection 
of  all  the  articular  surfaces,  even  where  one  0UI3"  is  injured.  When 
primaiy  resection  is  determined  on,  the  sooner  the  operation  is  done  the 
better  ;  when  a  secondary  operation  is  performed,  the  Surgeon  must  wait 
until  suppuration  is  fairl3^  established,  and  then  he  should  do  it  with  as 
little  delay  as  possible,  lest  hectic  or  p3"iemia  supervene.  The  operative 
procedure  necessaiy  for  the  complete  resection  of  a  compound  and 


Fig.  138. 


Apparatus  for  Wrist-Drop  after  Fracture  of  the 
Humerus. 


358 


SPECIAL  FKACTUKES. 


comminuted  fracture  of  the  bones  that  enter  into  the  conformation  of 
the  elbow-joint,  differs  in  no  material  respect  from  the  same  operation  for 
disease  of  the  articulation,  as  well  be  described  in  Chapter  XLIX. 

Fractures  of  the  Forearm. — 1.  The  only  fracture  of  the  bones  of 
the  forearm  that  commonly  occurs  in  the  vicinity  of  the  elbow-joint^  is 
that  of  the  Olec7'anon ;  this  almost  invariably  happens  from  falls  upon 
the  elbow,  and  hence  is  usually  accompanied  by  very  considerable  bruising 
and  swelling  of  the  parts.  It  may  possibly,  though  very  rarely,  from 
muscular  action.  The  displacement  is  usually  considerable,  the  detaclied 
fragment  being  drawn  upwards  by  the  triceps  muscle.  Occasionally, 
however,  when  the  ligamentary  expansion  of  the  tendon  of  this  muscle 
is  not  torn  through,  there  is  but  little  separation  of  the  fragments.  In 
the  majority  of  cases,  as  the  injury  takes  place  from  direct  violence, 
there  is  much  swelling  about  the  joint ;  and  not  unfrequently  the  fracture 
is  comminuted  or  compound. 

The  Treatment  is  best  conducted  by  moderately  straightening  the  arm, 
and  maintaining  it  in  that  position  b}^  means  of  a  w^ell-padded  light 
w^ooden  splint  laid  along  its  forepart.  But,  although  the  arm  should 
be  kept  nearly  straight,  it  should  not  be  quite  extended.  The  best  and 
most  easy  position  in  which  to  put  it  up  is  that  into  which  the  arm 
naturally  falls  when  extended ;  in  this  there  will  be  seen  to  be  slight 
flexion  at  the  elbow.  If  the  forearm  be  too  rigidly  extended  on  the  arm, 
it  may  be  carried  backwards  beyond  the  straight  line,  owing  to  the  loss 
of  the  resistance  of  the  olecranon  against  the  fossa  at  the  back  of  the 
humerus. 

In  Compound  fracture  of  the  olecranon,  when  an  attempt  is  made  to 
save  the  joint,  and  where  there  is  the  possibility  of  ankylosis,  the  semi- 
flexed  w^ould  be  preferable  to  the  straight  position.  In  such  cases  I 
have  found  it  most  comfortable  to  the  patient  to  rest  his  arm  slightly 
bent  on  a  pillow. 

Fracture  of  the  Coronoid  Process  of  the  Ulna  has  been  supposed  by 
many  Surgeons  to  be  a  common  complication,  and,  indeed,  a  cause  of  dis- 
'  location  of  the  ulna  backwards.  There  is  every  reason,  however,  to 
believe  that  this  is  an  error,  and  that,  in  point  of  fact,  it  is  one  of  the 
rarest  accidents  in  surgery — at  least  we  must  come  to  this  conclusion, 
if  we  are  to  judge  by  the  small  number  of  recorded  cases  or  of  preserved 
specimens  of  this  injury.  Hamilton  states  that  there  are  but  eight  cases 
on  record  in  which  the  symptoms  led  to  a  belief  that  this  accident  had 
occurred;  that  in  none  of  these  cases  were  the  symptoms  unequivocal, 
but  in  all  open  to  doubt ;  and  that  in  not  one  case  did  dissection  afford 
an  opportunity  of  positively  demonstrating  this  fracture.  There  are 
but  four  preparations  in  existence,  according  to  Hamilton,  illustrative 
of  this  injury,  and  all  these,  he  saj^s  are  doubtful.  In  the  cases  in  which 
this  accident  has  been  supposed  to  have  occurred,  the  injury  has  arisen 
from  falls  on  the  palm  of  the  hand,  by  which  the  ulna  has  been  driven 
backwards,  and  the  coronoid  process,  striking  against  the  lower  end  of 
the  humerus,  splintered  off.  In  a  case  related  by  Liston,  the  injury  is 
said  to  have  been  produced  by  muscular  action  in  a  boy,  who,  hanging 
for  a  length  of  time  by  his  hands  from  a  high  wall,  fell  to  the  ground, 
and  was  supposed  to  have  met  with  this  fracture.  Whether  the  fracture 
actually  occurred  in  this  case  is  doubtful;  and,  if  it  did,  it  is  still  more 
doubtful  whether  it  was  occasioned  by  the  contraction  of  the  brachialis 
anticus,  or  by  the  violence  of  the  fall. 

In  the  present  uncertain  state  of  our  knowledge,  I  forbear  to  speak 


FRACTURES  OF  LOWER  ENU  OF  RADIUS. 


859 


of  the  supposed  symptoms  of  this  accident.  If  it  were  suspected,  the 
proper  treatment  would  consist  in  placing  the  limb  in  angular  splints. 

2.  Fractures  of  the  Middle  of  the  Forearm  are  of  veiy  common  occur¬ 
rence,  both  bones  being  usually  broken,  with  much  shortening,  angular 
displacement,  and  creiutus.  Occasionally  one  bone  only  is  fractured, 
from  the  application  of  direct  violence.  AVhen  this  is  the  case,  more  at¬ 
tention  will  be  required  in  establishing  the  precise  nature  of  the  injury. 

The  Treatment  is‘ simple;  a  splint  somewhat  broader  than  the  arm 
should  be  placed  on  each  side  of  it,  and  a  narrow  pad  laid  along  the 
interosseous  space,  in  order  that  the  patency  of  this  may  be  preserved  ; 
no  bandage  should  be  placed  under  the  splint.  If  masses  of  callus  hap¬ 
pen  to  be  thrown  out  across  the  interosseous  space,  the  prone  and  supine 
movements  of  the  hand  will  be  lost,  and  the  utility  of  the  limb  greatly 
interfered  with. 

Compound  Fractures  of  the  Forearm  seldom  give  much  trouble  or 
require  amputation,  but  they  very  commonly  lead  to  obliteration  of  the 
interosseous  space,  and  thus  impair  the  utility  of  the  limb. 

3.  Fractures  of  the  Lower  Extremity  of  the  Radius^  near  the  wrist, 
are  very  frequent.  Their  importance,  not  only  in  a  diagnostic  point  of 
view,  but  also  in  reference  to  treatment,  has  caused  them  to  be  carefully 
studied  ;  and  their  nature  and  pathology  have  been  specially  investigated 
by  Colles,  Goyrand,  Yoillermier,  Xelaton,  and  R.  W.  Smith. 

These  fractures  usuallj"  occur  from  falls  upon  the  palm  of  the  hand, 
in  consequence  of  which  the  lower  end  of  the  bone  is  bent  back  and 
drawn  up ;  but  they  may  be  occasioned  by  direct  violence,  or  by  falls 
on  the  back  of  the  hand,  by  which  it  is  forcibly  bent  forwards.  In  this 
accident  the  radius  is  alw'a3^s  broken  across  transversel}',  usually  from 
three-quarters  to  one  inch  above  its  articular  surface.  The  fracture  may 
be  of  three  kinds;  1,  a  Simple  Transverse  one;  2,  with  Comminution  of 
the  Lower  Fragment;  and  3,  with  firm  Impaction  of  the  Upper  into 
the  Low^er  Fragment. 

The  Signs  of  this  accident  vary  greatljq  according  to  its  nature.  When 


Fig.  139. 


Fracture  of  Lower  End  of  Radius:  Side  View. 


simple^  there  is  usually  no  very  great  displace¬ 
ment  ;  but  there  will  be  noticed  some  tumefaction 
about  the  wrist,  a  sw'elling  at  its  dorsal  aspect,  loss 
of  the  movement  of  the  radius,  and  crepitus  on 
rotating  the  bone  whilst  the  hand  is  drawn  down. 

^When  the  fracture  is  comminuted^  and  still  more 
so  when  impacted^  the  signs  are  very  marked  and 
characteristic ;  so  much  so,  that  the^’  ma}’  always 
be  looked  upon  as  diagnostic  of  these  forms  of  this 
accident.  The  deformity  thus  occasioned  gives  rise 
to  a  remarkable  undular  distortion  of  the  wrist. 
On  looking  at  the  injured  limb  sideways,  it  will  be 
seen  that  there  is  a  considerable  dorsal  prominence 


Fig.  140. 


Fracture  of  Lower  End  of 
Radius:  Back  View. 


360 


SPECIAL  FRACTUKES. 


apparently  situated  on  the  back  of  the  carpus  (Fig.  139);  immediately 
underneath  this,  on  the  palmar  aspect  of  the  wrist,  just  opposite  tlie 
annular  ligament,  there  is  a  remarkable  hollow  or  arch,  most  distinctly 
marked  at,  and  indeed  confined  to,  the  radial  side  of  the  arm;  a  little 
above  this,  that  is  to  sa}’,  on  the  lower  part  of  the  palmar  aspect  of  the 
forearm,  there  is  another  rounded  prominence,  not  near!}"  so  large  or 
distinct,  however,  as  the  one  on  the  dorsal  aspect.  The  back  of  the  hand 
is  placed  somewhat  obliquely  to  the  axis  of  the  forearm  ;  the  ulnar  border 
being  somewhat  convex,  and  the  styloid  process  of  the  ulna  projecting 
sharply  under  the  skin  (Fig.  140).  The  radial  side  of  the  wrist  is,  on 
the  contraiy,  somewhat  concave,  appearing  to  be  shortened. 

The  pain  at  the  seat  of  injury  is  veiy  severe,  and  is  greatly  increased 
b}’’  moving  the  hand,  especially'  by  making  any  attempt  at  supination. 
The  hand  is  perfectly  useless,  the  patient  being  unable  to  support  it. 
All  the  power  of  rotating  the  radius  is  lost,  the  patient  moving  the  whole 
of  the  arm  from  the  shoulder  at  once,  and  thus  apparently',  but  not 
really',  pronating  and  supinating  it.  Crepitus  can  readily  be  felt  when 
the  fracture  is  simple  or  comminuted  ;  but  when  it  is  impacted,  the  most 
careful  examination  fails  to  elicit  it. 

The  Cau^e  of  the  particular  Deformity  that  is  observed,  and  indeed 
the  general  pathology'  of  the  injuiy,  has  been  the  subject  of  much  dis¬ 
cussion  ;  in  a  great  measure  owing,  I  believe,  to  the  opportunities  of 
dissecting  recent  fractures  of  this  kind  being  not  very^  frequent.  Sur¬ 
geons  are,  however,  now  generally  agreed  that  the  dorsal  prominence  is 
due  to  the  lower  fragment,  carrying  the  carpus  with  it,  being  displaced 
backwards  and  upwards ;  wdiilst  the  palmar  tumefiiction  is  due  to  the  pro¬ 
jection  forwards  of  the  lower  end  of  the  upper  fragment,  which  is  thrown 
into  a  state  of  forcible  pronation.  There  is  thus  a  double  cause  of  dis¬ 
placement  in  operation.  This  displacement  of  the  upper  fragment  is 
evidently  owing  to  the  pronatores  quadratus  and  teres ;  but  to  w'hat  is 

the  displacement  of  the  lower  frag¬ 
ment  due?  Is  it  to  the  peculiar 
manner  in  which  the  two  fragments 
are  locked  into  one  another?  or  is 
it  due  to  muscular  action  ?  Some 
years  ago  I  had  an  opportunity  of 
dissecting  and  carefullv  examining 
the  state  of  the  limb  in  a  woman  who 
died  of  paralysis  in  University  Col¬ 
lege  Hospital,  twelve  days  after 
meeting  with  this  accident.  On  ex¬ 
amining  the  left  arm,  which  present¬ 
ed  all  the  signs  of  this  injury  in  a 
marked  degree,  and  from  which  Fig. 
141  was  taken,  a  transverse  fracture 
of  the  radius  was  found  about  an 
inch  above  its  articular  surface.  The 
lower  fragment  was  split  into  three 
portions,  between  which  the  upper 
fragment  was  so  firmly'  impacted  to 
tlie  depth  of  more  than  half  an  inch, 
as  to  require  some  force  in  its  re¬ 
moval.  The  three  portions  into 
which  the  lower  fragment  was  split 
were  of  vciy  unequal  size;  the  two 


Fig.  141. 


Fig.  142. 


End  of  Eadius;  Dis¬ 
placement  of  Articular 
Surface. 


Fracture  of  Lower  End 
of  Eadius;  Displace¬ 
ment  of  Lower  Frag¬ 
ment. 


FRACTURES  OF  LOWER  END  OF  RADIUS. 


361 


posterior  ones  being  small,  consisting  merely  of  scales  of  bone ;  the  third 
fragment,  the  largest,  comprising  the  whole  of  the  articular  surface  of 
the  radius,  which  was  somewhat  tilted  upwards  and  backw^ards,  carrying 
the  hand  with  it.  To  this  fragment  were  attached  the  supinator  longus, 
and  the  greater  part  of  the  pronator  quadratus;  the  ligaments  and  the 
capsule  of  the  joint  were  uninjured. 

This  case  presented  the  appearance  usually  met  with  in  this  kind  of 
injury;  the  low'er  fragment  being  displaced  in  such  a  way  that  its  arti¬ 
cular  surface  looked  slightly  upwards,  backwards,  and  somewhat  out¬ 
wards,  so  as  to  be  twisted  as  it  were  upon  its  axis.  The  upper  frag¬ 
ment  was  found  in  a  state  of  pronation,  and  was  driven  into  and  firmly 
impacted  in  the  lower  one. 

That  the  deformity  in  this  case  was  the  result  of  impaction,  there 
could  be  no  doubt ;  and  that  impaction  is  the  cause  of  deformity  in 
many  cases,  is  proved  by  an  examination  of  several  specimens  of  con¬ 
solidated  fracture  of  the  radius  preserved  in  the  different  collections  in 
London,  and  by  the  difficulty  of  accounting  in  any  other  way  for  the 
occasional  impossibility  of  properl}^  reducing  these  fractures.  The  great 
traction  that  is  usually  required  to  remove  the  deformity,  and  the  absence 
of  distinct  crepitus  until  after  forcible  traction  has  been  employed,  indi¬ 
cate  the  existence  of  this  impaction. 

The  mode  in  which  the  impaction  and  consequent  deformity  occur, 
appears  to  me  to  be  as  follows.  When  a  person  falls  on  the  palm  of  the 
hand,  the  shock,  which  is  principally  received  on  the  ball  of  the  thumb 
and  the  radial  side  of  the  wrist,  is  not  directed  immediately  upw’ards  in 
the  axis  of  the  radius;  but  the  force  impinges  in  a  direction  obliquely 
from  before  backwards,  and  from  without  inwards,  as  well  as  from  below 
upwards,  and  thus  has  a  tendenc3',  as  soon  as  the  bone  is  broken,  to 
rotate  the  lower  fragment  on  its  own  axis,  and  to  tilt  the  articular  surface 
somewhat  upwards  and  outwards.  As  the  upper  fragment  descends,  its 
posterior  surface  of  compact  tissue  is  forced  into  the  cancellous  structure 
of  the  lower  fragment,  to  such  a  depth  as  wMll  admit  of  the  two  posterior 
portions  of  compact  tissue  coming  into  contact;  and  thus  the  upper  line 
of  compact  tissue  is  driven  into  the  lower  fragment,  to  an  extent  corre¬ 
sponding  to  the  degree  with  which  the  fragment  is  rotated  upwards 
and  backw'ards.  If  the  bone  be  brittle,  or  the  force  be  continued  after 
this  amount  of  impaction  has  taken  place,  the  lower  fragment  will  be 
splintered. 

The  prominence  of  the  stjdoid  process  of  the  ulna  is  the  result  of  the 
shortening  of  the  radial  side  of  the  W’rist  and  hand,  consequent  upon  the 
impaction. 

When  the  fracture  is  simple,  or  when  it  is  comminuted  without  im¬ 
paction,  I  agree  with  R.  W.  Smith  that  the  displacement  of  the  lower 
fragment  is  the  result  of  muscular  action  alone.  This  I  have  had  an 
opportunity' of  observing  in  the  following  case.  A  man,  64  years  of  age, 
fell  to  the  ground  from  a  height  of  twent3’'-five  feet.  In  his  fall  he  broke 
the  left  radius  just  above  the  wrist,  but  also  met  with  such  serious 
injuries  of  the  pelvis  and  abdomen,  that  he  died  in  an  hour  after  admis¬ 
sion  into  the  Hospital.  On  carefully  dissecting  the  arm  about  twenty- 
four  hours  after  death,  I  found  that  the  radius  was  fractured  transversely 
about  half  an  inch  above  its  lower  articular  end,  and  that  the  lower 
fragment  was  completely  comminuted.  The  wrist,  which  presented  all 
the  signs  of  this  fracture  in  a  veiy  marked,  but  not  an  extreme  degree, 
could  not  be  restored  to  its  normal  shape  b3^  any  amount  of  traction 
that  I  could  employ.  On  exposing  the  muscles  of  the  limb,  it  was  found 


862 


SPECIAL  FRACTURES. 


that  the  supinator  longus  was  attached  to  the  lower,  and  the  pronator 
quadratus  to  the  upper  fragment ;  the  latter  muscle  being  slightly  lace¬ 
rated  at  its  lower  part.  Tlie  upper  fragment  was  strongly  pronated. 
The  chief  cause  of  displacement,  and  the  main  obstacle  to  reduction,  was 
found  to  exist  in  the  two  radial  extensors  of  the  wrist,  the  tendons  of 
which  were  excessively  tense  ;  next  to  these,  the  special  extensors  of  the 
thumb  presented  most  tension,  and  then  the  supinator  longus,  which  was 
far  less  tense  than  either  of  the  other  sets  of  muscles,  but  especially  than 
the  radial  extensors,  tlie  tendons  of  which  were  strongly  defined.  On 
dividing  these  tendons,  and  on  pressing  the  lower  end  of  the  upper 
fragment  outwards,  reduction  was  easily  effected.  Here  the  displace¬ 
ment  was  evidently  due  to  two  causes.  The  upper  fragment  was  forcibly 
pronated  by  the  action  of  its  special  pronator;  and  the  hand,  with  the 
lower  fragment  attached,  was  drawn  upwards  and  backwards  by  and  in 
the  direct  line  of  the  radial  extensors  of  the  wrist.  There  was  no  im¬ 
paction  nor  interlocking  of  fragments,  but  perfect  mobilit}^  and  hence 
muscular  action  was  enabled  to  come  into  pla3\ 

In  another  case  which  I  have  since  dissected,  the  muscles  chiefl}’’  at 
fault  were  the  radial  extensors  ;  next  to  these  the  extensors  of  the  thumb; 
the  supinators  being  but  slightly  if  at  all  contracted. 

Besides  this  injuiy,  R.  W.  Smith  has  described  a  fracture  of  the  lower 
end  of  the  radius  in  consequence  of  falls  upon  the  back  of  the  hand,  in 
which  the  inferior  fragment  is  displaced  forwards.  In  these  cases  the 
character  of  the  deformitj^  indicates  tlie  nature  of  the  injuiy.  It  can 
readily  be  reduced,  with  a  feeling  of  crepitation,  by  traction. 

In  another  variety  of  fracture  in  this  situation,  the  lower  end  of  the 
radius  and  that  of  the  ulna  are  broken  off,  resembling  veiy  closely  dislo¬ 
cation  of  the  wrist  backwards.  But  the  facts  of  the  existence  of  grating, 
of  the  ready  reduction  of  the  swelling,  and  of  the  styloid  processes  of  the 
radius  and  of  the  ulna  continuing  to  be  attached  to  the  carpus,  and 
following  its  movements,  will  be  sufficient  to  establish  the  diagnosis. 

The  Treatment  of  the  ordinaiy  fracture  of  the  radius  near  the  wrist  is 
best  conducted  b}^  the  apparatus  introduced  ly  Nelaton  (Fig.  143). 


Fig.  143. 


Nelatoa’s  Apparatus  for  Treatment  of  Fracture  of  the  Lower  End  of  the  Radius. 


This  consists  of  a  pistol-shaped  wooden  splint,  which  is  placed  along  the 
outside  of  the  arm,  reaching  from  the  elbow  to  the  extremiy  of  the 
fingers.  Forcible  extension  and  counter-extension  should  be  practised, 
with  the  view  of  disentangling  the  fragments,  and  removing  the  dorsal 


FRACTURES  OF  THE  PELVIS. 


863 


prominence.  The  splint,  thickly  padded  opposite  the  lower  fragment, 
should  then  be  applied  to  the  outer  side  of  the  arm  ;  and  the  hand,  being 
well  brought  down  to  its  ulnar  side,  should  be  bandaged  to  the  bent 
part  of  the  splint.  Another  short  splint,  reaching  from  the  bend  of  the 
elbow  to  the  lower  extremity  of  the  upper  fragment,  should  now  be  placed 
along  the  inside  of  the  arm,  after  having  been  well  padded  along  its  radial 
border,  so  as  to  counteract  the  tendenc3^  to  pronation  of  this  part  of  the 
bone.  The  arm  must  then  be  placed  in  a  sling.  When  the  fracture  is 
impacted,  little  if  an^'  alteration  in  the  deformity  can  be  produced. 
When  it  is  mobile,  it  may  usually  be  brought  into  good  position.  The 
fracture  unites  in  the  course  of  a  month  or  five  weeks.  Passive  motion 
of  the  joint  may,  however,  often  be  commenced  at  an  earlier  period  than 
this,  with  great  advantage  to  the  patient,  more  particularly  when  the 
fracture  is  impacted.  It  will  be  at  least  three  months  before  the  stiffness 
of  the  hand  and  wrist,  the  latter  owing  to  fissure  into  the  joint,  are  so 
far  diminished,  even  by  the  use  of  friction  and  douches,  as  to  enable 
the  patient  to  use  the  fingers.  It  sometimes  happens  that  in  both  arms 
the  radius  is  broken  at  the  same  time  in  this  situation,  constituting  a 
somewhat  serious  condition,  inasmuch  as  the  patient  is  not  able  to  feed 
or  assist  himself  in  any  way  during  the  treatment. 

Fractures  of  the  Metacarpus  and  Fingers  are  of  so  simple  a 
character  in  every  waj^  as  scarcely  to  call  for  detailed  remarks.  In  the 
Treatment^  rest  of  the  part  upon  a  leather  or  pasteboard  splint  is  all  that 
is  requisite.  In  compound  fracture  of  these  bones,  every  effort  should 
be  made  to  save  the  part ;  if  removal  becomes  necessary,  it  should  be  to 
as  limited  an  extent  as  possible  (p.  63). 

FRACTURES  OF  THE  LOWER  EXTREMITY. 

Fractures  of  the  Pelvis. — The  danger  here  depends  not  so  much 
on  the  extent  of  the  fracture  as  on  its  complication  with  internal  injury, 
and  on  the  violence  with  which  it  has  been  inflicted.  Fracture  may 
extend  in  any  direction  across  the  pelvic  bones,  though  most  commonly 
it  passes  through  the  rami  of  the  os  pubis  and  ischium,  and  across  the 
body  of  the  ilium,  near  the  sacro-iliac  articulation.  In  some  cases  the 
symphysis  is  broken  through,  and  in  others  the  fracture  extends  across 
the  bod^"  of  the  pubic  bone. 

It  occasionally  happens  that  a  portion  of  the  crest  of  the  ilium  is 
broken  off';  but  this  is  of  little  consequence,  even  though  the  bone 
continue  depressed.  When  the  rami  of  the  os  pubis  and  ischium,  or  the 
whole  body  of  the  ilium,  are  broken  through,  there  is,  of  course,  con¬ 
siderable  danger  from  internal  injury.  If  the  patient  escape  this,  the 
fracture,  however  extensive  it  ma^^  be,  ma}’’  unite  favorabl3^  A  patient, 
under  my  care  at  the  Hospital,  had  a  fracture  extending  through  the  rami 
of  the  pubes  and  ischium  in  front,  and  behind  across  the  ilium,  in  a  line 
parallel  with  and  close  to  the  sacro-iliac  symphj^sis,  so  as  completely  to 
detach  one-half  of  the  pelvis ;  he  recovered,  however,  without  an^^  bad 
consequences  occurring. 

The  nature  of  the  injury  is  usually  apparent  from  the  great  degree  of 
direct  violence  that  has  been  inflicted  upon  the  part;  from  the  pain  that 
the  patient  experiences  in  moving  or  in  coughing  ;  from  the  impossibility 
to  stand,  in  consequence  of  a  feeling  as  if  the  body  were  falling  to  pieces 
when  he  attempts  to  do  so ;  and  from  the  read^^  mobility  of  the  part  and 
crepitus  on  seizing  the  brim  of  the  pelvis  on  each  side,  and  moving  it  to 
and  fro,  or  on  rotating  the  thigh  of  the  affected  side.  In  examining  a 
patient  with  suspected  fracture  of  the  pelvis,  care  should,  however,  be 


884 


SPECIAL  FRACTURES. 


taken  not  to  push  the  investigation  too  closel}',  lest  injury  be  inflicted 
by  the  movement  of  the  fragments.  In  those  cases,  indeed,  in  which 
the  fracture  does  not  extend  completel}’^  across  the  pelvis,  or  in  which  it 
is  seated  in  the  deeper  parts  of  the  ischium,  an  exact  diagnosis  ma}'  be 
impossible. 

In  fractured  pelvis,  the  principal  sources  of  danger  arise  from  injury 
to  the  bladder  and  urethra,  with  consequent  extravasation  of  urine;  from 
laceration  of  the  rectum,  or  fracture  of  the  acetabulum;  and  in  examin¬ 
ing  the  pelvis  no  rough  handling  should  be  allowed,  lest  injury  to  the 
pelvic  organs  be  inflicted  by  the  fragments. 

In  the  Treatment^  the  first  thing  to  be  done  is  to  pass  a  catheter  into 
the  bladder,  in  order  to  ascertain  the  condition  of  the  urinary  apparatus; 
if  it  be  injured,  recourse  must  be  had  to  measures  that  will  be  descril)ed 
in  speaking  of  laceration  of  the  urethra.  The  next  thing  is  to  keep  the 
part  perfectly  quiet,  so  as  to  bring  about  union.  With  this  view,  a 
I^added  belt,  or  a  broad  flannel  roller,  should  be  tightly  applied  round 
the  pelvis,  the  patient  lying  on  a  hard  mattress.  The  knees  may  then 
be  tied  together,  and  a  leather  or  gutta-percha  splint  put  upon  the  hip 
of  the  side  affected,  so  as  to  keep  the  joint  quiet,  and  to  prevent  all 
displacement  of  the  fragment.  If  the  urethra  have  been  lacerated,  it 
must  be  borne  in  mind  that,  however  completely  the  patient  may  recover 
from  the  fracture,  he  will  most  certainly  become  the  subject  eventually 
of  the  most  troublesome  and  intractable  form  of  urethral  stricture — 
the  traumatic. 

Fracture  of  the  Acetabulum  is  an  accident  that  can  only  occur  as  the 
result  of  very  great  violence  directl}’’  applied  to  the  hip.  It  may  take 
place  in  two  situations;  either  through  the  floor  of  the  cavitj*,  or  only 
through  the  rim,  a  portion  of  which  is  detached.  It  is  probablj^  occa¬ 
sioned  in  most  instances  b}^  the  head  of  the  thigh-bone  being  driven 
forcibly  against  the  surface  of  the  acetabulum.  Hence,  when  the  rim  is 
broken  it  is  usually  the  posterior  part  that  is  detached,  and  the  head 
of  the  femur  slips  out  upon  the  dorsum  ilii. 

Fracture  through  the  floor  of  the  acetabulum  is  usually  complicated 
with  extensive  comminution  of  the  pelvic  bones  and  serious  internal 
injuiy,  so  as  to  be  followed  b}"  death.  In  the  UniversiW  College  Museum 
is  a  preparation  of  a  fracture  of  the  acetabulum,  with  comminution  of 
its  floor  and  of  the  ilium.  Sanson  and  Sir  A.  Cooper  have  seen  the  bone 
resolved  into  its  three  primitive  fragments;  and  in  some  cases  the  com¬ 
minution  has  been  so  great  that  the  head  of  the  femur  has  been  thrust 
into  the  pelvic  cavit3\ 

In  such  extensive  and  grave  injuries  as  these,  the  Surgeon  can  do  little 
more  than  support  the  pelvis  with  a  padded  belt,  and  place  the  limb  on 
the  long  splint. 

When  a  portion  of  the  rim  of  the  acetabulum  is  detached,  as  the  result 
of  direct  Auolence,  the  head  of  the  femur  will  slip  out  upon  the  dorsum 
ilii,  or  into  the  sciatic  notch,  and  the  signs  of  ilio-sciatic  dislocation 
manifest  themselves.  In  a  case  of  this  kind,  which  w’as  under  my  care 
at  the  Hospital  in  a  muscular  man  about  thirt}",  the  shortening  inversion, 
and  displacement  of  the  head  of  the  bone  into  the  sciatic  notch,  w^ere  all 
well  marked.  Traction  readil}"  effected  reduction,  with  distinct  crepitus; 
but,  as  soon  as  extension  was  discontinued,  the  head  of  the  bone  slipped 
back  into  the  sciatic  notch. 

The  diagnosis  in  this  case  was  made,  and  in  similar  instances  may 
readily  be  effected,  by  attention  to  three  circumstances:  the  dislocation, 
its  ready  reduction  with  crepitus,  and  its  immediate  return  when  the 
limb  is  left  to  itself. 


FRACTURES  OF  THE  SACRUM  AND  COCCYX. 


365 


The  Treatment  consists  in  the  application  of  the  long  splint  with  a 
broad  padded  belt,  so  as  to  secure  steadiness  of  the  head  of  the  bone. 
But  with  every  care  a  return  of  displacement  will  readily  take  place, 
and  an  unsalisfactoiy  result  can  scarcely  be  avoided;  shortening  of  the 
limb,  and  consequent  lameness,  being  almost  inevitable. 

Fractures  of  the  Sacrum  are  excessively  rare,  except  as  the 
result  of  gunshot  injuiy.  When  occurring  from  other  causes,  such  as 
falls,  the}"  are  almost  invariably  associated  with  fracture  of  the  pelvic 
bones,  and  theji  they  have  always  been  fatal.  The  records  of  surgery 
contain  but  a  very  few  observations,  probably  not  more  than  six  or 
eight,  of  uncomplicated  fracture  of  the  sacrum  arising  from  other  causes 
than  gunshot.  I  have  had  two  cases  of  fracture  of  the  sacrum  under 
my  care.  Both  had  a  rapidly  fatal  issue.  In  one  there  was  also  fracture 
through  the  pubic  bone;  in  the  other,  the  sacrum  was  the  only  bone 
injured.  In  it,  the  fracture  was  the  result  of  a  blow  on  the  lower  part 
of  the  back  by  the  buffer  of  a  railway  carriage.  The  preparation  is  in 
the  University  College  Museum.  The  only  other  preparation  with  which 
I  am  acquainted,  is  one  in  the  Museum  of  the  College  of  Surgeons. 
These  fractures  are  almost  invariably  transverse,  with  displacement 
forwards  of  the  upper  margin  of  the  lower  fragment.  This  was  the 
case  in  both  the  instances  under  my  care ;  but  Bicherand  has  published 
a  case  in  which  this  bone  was  split  A'ertically  in  consequence  of  a  fall  on 
the  face;  and  its  crucial  and  multiple  fracture  has  been  described  by 
others.  The  injury  can  necessarily  only  arise  from  direct  violence  of  a 
severe  character,  and  is  attended  by  much  extravasation  and  pain, 
together  with  neuralgia  along  the  course  of  the  posterior  sacral  nerves, 
which  maybe  implicated  in  or  irritated  by  the  fracture.  The  Treatment 
would  consist  in  the  application  of  a  padded  i)elvic  band. 

The  Coccyx,  though  more  exposed,  is  seldom  broken.  But  fracture 
of  it  may  occur  from  falls  backwards,  or  from  direct  blows  on  the  part, 
the  tip  being  bent  forcibly  forwards,  and  the  elements  of  the  bone  sepa¬ 
rated.  The  pain  in  these  cases  is  excessively  severe,  owing  to  the  bruis¬ 
ing  of  the  ligamentous  and  tendinous  expansions  that  coA"er  the  bone. 
It  is  greatly  increased  in  sitting  and  walking,  and  in  defecation.  It  is 
sometimes  removed  on  reducing  the  fractured  and  displaced  fragments 
by  pressure  through  the  rectum,  but  may  continue  for  months,  and  even 
longer,  constituting  a  truly  neuralgic  affection  of  the  part.  South  relates 
the  case  of  a  gentleman  who  broke  his  coccyx  by  sitting  on  the  edge  of 
a  snuff-box,  and  who  suffered  such  severe  pain  that  he  was  obliged  to  wear 
a  pad  on  each  tuberosity  of  the  ischium,  in  order  that  the  coccyx  might 
be  in  a  kind  of  pit,  and  free  from  all  pressure  when  he  sat. 

Under  the  term  Coccydynia^  Sir  J.  Y.  Simpson  has  described  a  painful 
affection  of  the  coccyx  and  its  neighboring  structures,  which  chiefly  occurs 
in  w’omen,  commonly  as  the  result  of  injury,  and  is  often  very  severe 
and  persistent,  so  as  to  prevent  the  patient  from  sitting,  or  even  walking 
with  comfort.  It  is  an  affection  that  closely  resembles  in  its  symptoms 
the  pain  occasioned  by  fissure  or  ulcer  of  the  anus  and  rectum.  It  usu¬ 
ally  arises  from  a  blow  on  the  part,  though  it  appears  sometimes  to  origi¬ 
nate  independently  of  any  external  violence.  The  Treatment  recom¬ 
mended  by  Sir  J.  Y.  Simpson  consists  in  the  free  subcutaneous  division, 
by  means  of  a  tenotome,  of  the  muscular  and  tendinous  structures  con¬ 
nected  with  the  coccyx.  The  section  of  these  structures  is  made  first  on 
one  side,  then  on  the  other,  and  finally  around  the  tip,  so  as  completely 
to  isolate  the  bone.  The  good  effects  of  the  operation  are  usually  imme¬ 
diate,  the  pain  ceasing  at  once. 


366 


SPECIAL  FRACTURES. 


Fractures  of  the  Thigh-Bone  are  of  great  practical  interest,  from 
their  freqnenc3^  and  severity'.  The}"  ma}"  occur  in  the  Upper  Articular 
End  of  the  bone,  in  its  Shaft,  or  in  its  Lower  End.  In  these  different 
situations,  eveiy  possible  variet}-  of  fracture  is  often  met  with. 

1.  Fractures  of  the  Pelvic  End  of  the  Bone  ma}-  be  divided  into  those 
that  occur  through,  the  Neck  Within  the  Capmle  of  the  joint,  those  that 
occur  Outside  the  Capsule^^nd  those  that  implicate  the  Trochanters  alone. 

Intracapsular  Fracture  of  the  Xeck  of  the  Thigh  Bone  ma}’’  be  either 
simple,  the  bone  being  merel}"  broken  across  ;  or  impacted,  the  lower 
portion  of  bone  being  driven  into  the  upper  fragment. 

This  intracapsular  fracture  ma}"  almost  be  looked  upon  as  a  special 
injuiy  of  advanced  life,  being  but  seldom  met  with  in  persons  under  lift}". 
Thus  Sir  A.  Cooper  states  that,  of  251  cases  with  which  he  met  in  the 
course  of  his  practice,  onl}"  two  were  in  persons  below  this  age.  Itma}*, 
however,  happen  at  an  earl}"  period  of  life  :  Stanley  has  recorded  the  case 
of  a  lad  of  eighteen,  who  met  with  this  injury,  and  Hamilton  has  described 
it  as  occurring  in  a  girl  aged  sixteen  and  in  a  man  aged  twenty-five.  A 
remarkable  circumstance  in  connection  with  this  accident  is,  that  it  com¬ 
monly  happens  from  very  slight  degrees  of  violence,  indeed  almost  spon¬ 
taneously.  Thus,  the  jarring  of  the  foot  in  missing  a  step  in  going  down 
stairs,  catching  the  toes  under  the  carpet,  tripping  upon  a  stone,  or  en- 
tano;ling  the  foot  in  turning  in  bed,  are  sufficient  to  occasion  it.  It  is 
especially  in  women  that  this  injury  is  met  with. 

Cause. — The  occurrence  of  this  fracture  in  old  age  is  owing  indirectly 
to  the  changes  in  structure,  shape,  and  position  of  the  head  and  neck  of 
the  femur  with  advancing  years.  The  cancellous  structure  of  these  pans 
becomes  expanded,  the  cells  large,  loose,  and  loaded  with  fluid  fat.  The 
compact  structure  becomes  thinned,  and  proportionately  weakened,  espe¬ 
cially  about  the  middle  and  under  part  of  the  neck,  which,  appearing  to 
yield  to  the  weight  of  the  body,  is  shortened  ;  and,  instead  of  being  oblique 
in  its  direction,  becomes  horizontal,  inserted  nearly  at  a  right  angle  into 
the  shaft.  In  consequence  of  these  changes  in  structure  and  position, 
it  becomes  less  able  to  bear  any  sudden  shock  by  which  the  weight  of 
the  body  is  throw-n  upon  it,  and  snaps  under  the  influence  of  very  slight 
degrees  of  violence.  When  it  breaks,  the  capsule  may  remain  uninjured, 
but  the  prolongation  of  it  which  invests  the  neck  of  the  bone  is  usually 
torn  through.  In  some  cases,  however,  this  cervical  reflection  is  not  rup¬ 
tured,  the  lower  portion  of  it  especially  often  remaining  for  some  length 
of  time  untorn,  at  last,  however,  giving  way  under  the  influence  of  the 
movements  of  the  limb,  or  by  being  softened  by  local  inflammatory  action. 
As  the  violence  occasioning  the  fracture  is  generally  but  slight,  and  as 
the  vascularity  of  this  portion  of  the  bone  is  trifling  in  old  people,  there 
is  but  little  extravasation  of  blood. 

The  fragments  are  almost  always  so  separated  that  the  fractured  sur¬ 
faces  are  not  in  apposition  ;  the  upper  end  of  the  lower  fragment  is  drawn 
above  and  to  the  outer  side  of  the  head  of  the  bone,  and  at  the  same  time 
is  twisted  so  that  its  broken  surface  looks  forwards.  The  head  remains 
in  the  acetabulum,  attached  by  the  ligamentum  teres,  and  sometimes  pre¬ 
serving  a  connection  with  the  lower  fragment,  through  the  medium  of 
some  uutorn  portions  of  the  fibrous  membrane  investing  the  neck.  R. 
W.  Smith  has  observed,  that  in  some  instances  the  two  fragments  become 
interlocked  or  dovetailed  as  it  were  into  one  another,  in  consequence  of 
the  line  of  fracture  beins;  irretjular  and  dented. 

o  o  ^ 

Signs. — These  are,  alteration  in  the  shape  of  the  hip,  crepitus  and  pain 
at  the  seat  of  injury,  and  inability  to  move  the  limb,  with  shortening  and 


INTRACAPSULAR  FRACTURE  OF  THIGH-BONE.  867 


eversion  of  it.  These  we  must  consider  separately,  as  important  modi¬ 
fications  of  each  are  sometimes  noticed. 

ThQ  Altei'ation  in  the  Shape  of  the  Hip  is  evidenced  by  some  flattening 
of  the  part,  the  trochanter  not  being  so  prominent  as  usual.  This  process 
is  also  approximated  to  the  anterior  superior  spine  of  the  ilium  ;  and,  on 
rotating  the  limb,  it  is  felt  to  move  to  and  fro  under  the  hand,  not  de¬ 
scribing  the  segment  of  a  circle  so  distinctly  as  on  the  sound  side.  The 
circle  described  by  the  trochanter  on  the  injured  side  is  much  smaller 
than  that  on  the  sound  side.  In  the  sound  limb,  the  trochanter  describes 
the  segment  of  a  circle  having  a  radius  equal  to  the  length  of  the  head 
and  neck  of  the  bone.  On  the  injured  side,  the  circle  has  a  radius  equal 
only  to  the  length  of  that  portion  of  the  neck  that  still  remains  attached 
to  the  shaft  of  the  bone.  During  this  examination  crepitus  will  usually 
be  felt,  though  this  occasionally  is  very  indistinct  and  even  absent,  more 
especially  if  the  limb  be  not  well  drawn  down  at  the  time  it  is  rotated,  so 
as  to  bring  the  fractured  surfaces  into  apposition  ;  and  much  pain  is  pro¬ 
duced  bv  any  movement  of,  or  pressure  upon,  the  joint. 

The  Attitude  of  the  Limhds  so  peculiar,  as  in  general  to  indicate  at 
once  to  the  Surgeon  what  has  happened.  There  is  a  striking  appearance 
of  helplessness  about  it.  As  the  patient  is  lying  on  his  back  in  bed  it  is 
everted;  shortened  somewhat,  with  the  knee  semi-flexed;  on  requesting 
him  to  lift  it  up,  he  makes  ineffectual  attempts  to  do  so,  and  at  last  ends 
by  raising  it  with  the  toe  of  the  opposite  foot,  or  with  his  hands.  When 
he  is  taken  out  of  bed  and  placed  upright,  the  injured  limb  hangs  use¬ 
lessly,  with  the  toes  pointing  downwarcls  and  the  heel  raised  and  point¬ 
ing  to  the  inner  ankle  of  the  sound  side,  the  patient  being  unable  to  rest 
upon  it  (Fig.  144).  In  some  cases,  however,  after  tlie  fracture  has 
occurred,  the  patient  can  lift  the  limb  some¬ 
what,  but  with  much  exertion,  from  the  couch 
on  which  he  is  lying;  or  can  even  manage  to 


Fig. 


144. 


walk  a  few  paces,  or  to  stand  for  a  few  minutes 
upon  it,  with  much  pain  and  difficulty.  This 
is  owing  either  to  the  cervical  reflection  of  the 
capsule  being  untorn,  or  else  to  the  fragments 
not  being  separated,  having  become  locked  into 
one  another;  and  it  usually  occurs  in  those 
cases  4i  which  the  other  and  more  characteristic 
signs  of  this  fracture  are  not  well  marked. 

Eversion  of  the  limb  is  almost  an  invariable 
accompaniment  of  this  fracture.  It  is  most 
marked  in  those  cases  in  which  the  shortening 
is  most  considerable.  This  eversion  has  usu¬ 
ally  been  attributed  to  the  action  of  the  external 
rotator  muscles,  which  are  inserted  into  the 
upper  end  of  the  lower  fragment.  But  I  cannot 
consider  this  as  the  onl}",  or  indeed  the  principal 
cause  of  this  position  ;  for,  not  only  is  it  very 
difficult  to  understand  how  these  muscles  can 
rotate  outwards  the  limb  after  their  centre  of 
motion  has  been  destroved  by  the  fracture  of 
the  neck  of  the  femur,  their  action  being  rather 
in  a  direction  backwards  than  rotary  under 
these  circumstances,  but  we  find  that  the  limb 
falls  into  an  everted  position  in  those  cases  in  which,  the  fracture  being 


.4.Uitade  of  Limb  iu  Intracap- 
sular  Fracture  of  the  Xeck  of  the 
Thigh-Bone. 


in  the  shaft,  and 


altogether 


below  the  insertions  of  these  muscles. 


no 


868 


SPECIAL  FRACTURES. 


influence  can  be  exercised  by  them  on  the  lower  fragment.  I  look  upon 
eversion  in  cases  of  fractured  thigh  as  not  being  a  result  of  muscular 
action  at  all,  but  simply  the  natural  attitude  into  which  the  limb  falls 
when  left  to  itself.  Even  in  the  sound  state,  eversion  takes  place  spon¬ 
taneously  whenever  muscular  action  is  relaxed,  as  during  sleep,  in  par¬ 
alysis,  or  in  the  dead  body;  and  in  the  injured  limb,  in  which  tliere  is, 
as  it  were,  a  suspension  of  muscular  action,  it  will  occur  equall3\  Indeed, 
the  shortening  that  takes  place  will  specially  tend  to  relax  the  external 
rotators,  and  thus  still  more  prevent  their  influencing  the  position  of  the 
limb. 

Inversion  of  the  foot  in  cases  of  intracapsular  fracture  has  been  some¬ 
times  noticed.  I  have  seen  two  instances :  Smith,  Stanlej^,  and  other 
Surgeons,  also  record  cases.  This  deviation  from  the  usual  S3’mptoms 
of  this  injury  has  been  attributed  b\^  some  to  the  cervical  ligament  not 
having  been  torn  through  at  its  inner  side,  but  that,  as  Stanlej^  observes, 
while  it  rna}'  prevent  eversion,  cannot  occasion  inversion  ;  b\’  others  to 
the  fact  of  the  lower  fragment  in  these  cases  being  alwa3’S  found  in  front 
of  the  upper  one.  This  circumstance,  which  is  much  insisted  on  by  R. 
W.  Smith,  appears  to  me  to  be  rather  the  result  than  the  cause  of  the 
inversion  ;  for  an3"  traction  inwards  of  the  longer  fragment  by  the  ad¬ 
ductor  muscles  of  the  thigh  w'ould  have  a  tendency  to  draw  the  upper 
end  of  this  fragment  to  the  anterior,  or,  in  other  w^ords,  the  inner  side 
of  the  upper  one.  I  am  rather  disposed  to  think  that  this  inversion  is 
owdng,  in  some  cases  at  least,  to  the  external  rotators  being  paral3'zed 
by  the  violence  they  receive  from  the  injuiy  that  occasions  the  fracture, 
and  that  thus  the  adductors,  acting  without  antagonists,  draw  the  thigh 
and  with  it  the  leg  inwards.  In  both  instances  that  fell  under  my  ob¬ 
servation,  and  in  some  of  those  that  have  been  published,  the  fracture 
resulted  from  severe  direct  injurv  to  the  hip,  and  was  not  occasioned  by 
the  patient  jarring  his  foot,  or  b3''  an3'  indirect  violence  operating  at  the 
end  of  the  limb. 

The  shoi'iening  in  cases  of  fracture  within  the  capsule  seldom  exceeds, 
in  the  first  instance,  from  half  an  inch  to  an  inch,  depending  on  the  extent 
of  the  separation  betw^een  the  fragments  ;  it  cannot,  indeed,  in  the  earh' 
periods  of  the  fracture,  veiy  w’ell  exceed  the  width  of  the  neck  of  the 
bone,  as  the  capsule  is  usuall)^  not  torn  through.  After  the  fracture 
has  existed  some  time,  the  capsule  of  the  joint  ma3^  yield,  allowing  greater 
separation  between  the  fragments,  and  then  it  may  amount  to  two,  or 
even  tw'o  and  a  half  inches.  It  not  uncommonl3^  happens  that  the 
shortening,  wiiicii  is  at  first  but  veiy  slight,  about  half  an  inch,  suddenl3^ 
increases  to  an  inch  or  more  :  this  is  accounted  for  on  the  supposition  of 
the  cervical  ligament,  which  had  at  first  not  been  completel3^  ruptured, 
at  last  giving  way  entirel3" ;  or  it  may  be  owing  to  the  fragments  which 
were  originalh'  interlocked  becoming  separated.  It  is  in  those  cases  in 
wiiich  there  is  but  slight  separation  of  the  fragments,  and  consequentl3^ 
little  shortening,  that  the  other  signs  of  fracture  are  not  \ery  strongly 
marked,  and  that  the  patient  preserves  some  powder  over  the  movements 
of  the  limb. 

The  Constilutional  Disturbance  in  intracapsular  fracture  of  the  neck 
of  the  femur  in  old  people,  though  trifling  at  first,  often  eventually  be¬ 
comes  considerable;  and  the  injury  frequentl3"  terminates  fatally,  from 
the  supervention  of  congestive  pneumonia,  an  asthenic  state  of  S3'stem, 
or  sloughing  of  the  nates  from  confinement  to  bed  during  treatment. 
Hence  this  injuiy  must  ahva3’s  be  considered  as  very  dangerous,  and  not 
unfrequentl3'  fatal. 


INTRACAPSULAR  FRACTURE  OF  THIGH-BOXE.  869 


Mode  of  Union. — The  treatment  of  these  fractures  turns  in  a  great 
measure  upon  the  view  that  is  taken  of  their  mode  of  union,  and  on  the 
constitutional  condition  of  the  patient.  In  some  cases  no  union  occurs, 
but  the  head  of  the  bone  remains  in  the  acetabulum,  being  hollowed  into 
a  smooth,  hard,  cup-shaped  cavit}’,  in  which  the  neck,  which  has  become 
rounded  off  and  polished,  is  received,  and  plays  as  in  a  socket. 

The  union  of  the  intracapsular  fracture  of  the  neck  of  the  femur  takes 
place,  however,  in  the  great  majority  of  cases  by  fibrous  tissue.  This 
is  owing  to  two  causes  ;  in  the  first  place,  to  the  circumstance  (which  I 
look  upon  as  the  most  important)  that  the  fractured  surfaces  are  not  in 
apposition  with  one  another  ;  and  secondly,  that  the  vascular  supply 
sent  to  the  head  of  the  bone,  consisting  onl}’  of  the  blood  that  finds  its 
way  through  the  vessels  of  the  ligamentum  teres,  is  insufficient  for  the 
proper  production  of  callus.  ^ 

In  some  cases,  however,  bony  union  takes  place.  This  can  only  hap¬ 
pen  when,  in  consequence  of  the  cervical  ligament  being  untoru,  or  the 
fracture  being  impacted,  the  surfaces  are  kept  in  some  degree  of  appo¬ 
sition,  and  the  vascular  supplj’’  to  the  head  of  the  bone  is  speedily  aug¬ 
mented  by  the  blood  carried  into  it  through  the  medium  of  the  plastic 
matter  that  is  deposited  between  the  fragments.  In  no  other  circum¬ 
stance  is  it  probable  that  osseous  union  takes  place  in  these  fractures  : 
hence  the  infrequency  of  its  occurrence,  there  being  in  all  probability  not 
more  than  eighteen  or  twenty  cases  on  record  as  having  thus  terminated 
in  this  countiy.  When  bony  union  has  taken  place,  the  head  will  usually 
be  found  to  be  somewhat  twisted  around  in  such  a  way  that  it  looks 
towards  the  lesser  trochanter,  owing  to  the  eversion  that  has  taken  place 
in  the  lower  fragment. 

Treatment. — As  these  fragments  do  not  unite  by  bone,  unless  the 
fragments  be  in  good  contact,  it  is  useless  to  confine  the  patient  to  bed 
for  any  long  period,  if  the  signs,  especiall}’  the  amount  of  shortening., 
indicate  considerable  separation  between  the  fragments,  or  if  the  patient 
be  very  aged  and  feeble.  In  these  circumstances,  lengthened  confine¬ 
ment  to  bed  most  commonly  proves  fatal  by  the  depressing  influence 
which  it  exercises  on  the  general  health,  by  the  intercurrence  of  visceral 
disease,  or  b}"  the  supervention  of  bed-sores.  It  is  therefore  a  good 
plan  to  keep  the  patient  in  bed  merely  for  two  or  three  weeks,  until  the 
limb  has  become  somewhat  less  painful,  the  knee  being  well  supported 
upon  pillows.  After  this  time,  a  leather  splint  should  be  fitted  to  the 
hip,  and  the  patient  be  allowed  to  get  up  upon  crutches.  There  will  be 
lameness  during  the  remainder  of  life  ;  but,  with  the  aid  of  a  stick  and 
properly  adjusted  splint,  but  little  inconvenience  will  be  suffered. 

When  the  fragments  do  not  appear  to  be  much  separated,  there  being 
but  little  shortening  and  indistinct  crepitus,  and  more  particularly*  if 
the  patient  be  not  very  aged,  and  in  other  respects  sound  and  well,  an 
attempt  may  be  made  to  procure  osseous  union.  This  may  be  done  by 
the  application  of  the  long  thigh-splint ;  or,  if  this  cannot  very  readily 
be  borne,  by  the  double  inclined  plane,  with  a  padded  belt  strapped 
round  the  hips.  This  apparatus  should  be  kept  applied  for  at  least 
two  or  three  months,  when  a  leather  splint  may  be  put  on  and  the 
patient  move  about  upon  crutches.  During  the  whole  of  the  treatment, 
a  generous,  and  even  stimulating  diet  should  be  ordered,  and  the  pa¬ 
tient  kept  on  a  water-bed  or  cushion.  In  the^e  fractures  of  the  neck  of 
the  femur,  the  starched  bandage  will  often  be  found  to  be  most  useful. 
It  may^  be  applied  as  in  fractured  thigh,  but  should  have  additional 
strength  in  the  spica  part,  and  indeed  may  be  provided  with  a  small 
VOL.  I. — 24 


370 


SPECIAL  FRACTUEES. 


pasteboard  cap  so  as  to  give  more  efficient  support.  In  old  people,  this 
plan  of  treatment  is  especiallj^  advantageous,  as  it  enables  them  to  sit 
up  or  even  to  walk  about,  and  thus  prevents  all  the  ill  effects  of  long 
.confinement  in  bed. 

Extracapsular  Fracture  of  the  Nech  of  the  Thigh-bone  is  commonly 
met  with  at  an  earlier  period  of  life  than  the  injury,  which  has  just  been 
described,  being  most  frequent  between  the  ages  of  thirty  and  forty,  but 
it  is  also  met  with  at  advanced  periods  of  life.  It  is  the  result  of  the 
application  of  great  and  direct  violence  upon  the  hip,  and  occurs  equally 
in  both  sexes. 

This  fracture  ma}^  be  of  two  kinds;  the  simple  or  the  impacted.  In 
both  cases  the  neck  of  the  bone  is  commonly  broken  at,  or  immediately 

outside,  the  insertion  of  the  capsule  of  the  joint. 
The  fracture  is  almost  invariably  comminuted ; 
indeed,  I  have  never  seen  a  case  in  which  the  great 
trochanter  was  not  either  detached  or  splintered 
into  several  fragments.  In  many  instances  the 
lesser  trochanter  is  detached,  and  the  upper  end 
of  the  shaft  injured  (Fig.  145).  This  splintering 
of  the  trochanter  is  owing  to  the  same  violence 
that  breaks  the  bone  forcing  the  lower  end  of  the 
neck  into  the  cancellous  structure  of  this  process, 
and  thus,  by  a  wedge-like  action,  breaking  it  into 
fragments.  When  the  neck  continues  locked  in  be¬ 
tween  these,  we  have  the  impacted  form  of  frac¬ 
ture. 

The  Signs  of  extracapsular  fracture  vary  accord¬ 
ing  as  it  is  simple  or  impacted ;  but  in  both  cases 
they  partake  of  the  general  character  of  those  of 
fracture  within  the  capsule.  The  individual  signs, 
however,  present  certain  well-marked  differences. 

The  hip  will  usually  be  found  much  bruised  and  swollen  from  ex¬ 
travasation  of  blood,  which  is  often  considerable. 

In  the  simple  fracture,  the  crepitus  is  A^ery  distinct  and  loud,  being 
readily  felt  on  laying  the  hand  upon  the  trochanter,  and  moving  the 
limb.  The  separate  fragments  into  which  the  trochanter  is  splintered 
may  occasionally  be  felt  to  be  loose.  The  pain  is  A^ery  seA'ere,  and 
greatly  increased  by  any  attempt  at  moving  the  joint,  which  to  the 
patient  is  impossible. 

The  eversion  is  usuall}’’  strongly  marked,  and  the  position  of  the  limb 
is  characteristic  of  complete  want  of  power  in  it.  Inversion  occurs  more 
frequentl}"  in  this  fracture  than  in  that  within  the  capsule.  Smith  finds 
that  of  7  cases  of  iiwersion  of  the  limb  in  fractures  of  the  neck  of  the 
femur,  5  occurred  in  the  extracapsular  fracture ;  and  of  15  cases  of 
intracapsular  fracture,  this  condition  was  met  with  in  3.  When  there  is 
much  comminution  of  the  trochanter,  the  foot  will  commonly  remain  in 
any  position  in  which  it  is  placed,  but  generally  has  a  tendency  to 
rotate  outwards. 

The  shortening  of  the  limb  is  very  considerable,  being  neA^er  less  than 
from  an  inch  and  a  quarter  to  two  inches  and  a  half,  and  often  extend¬ 
ing  to  three  or  four  inches. 

The  Imjjacted  Extracapsular  Fracture  of  the  neck  of  the  thigh-bone 
occurs  when,  in  consequence  of  a  heavy  fall  on  the  hip,  the  neck  is 
broken  across  at  its  root,  and  the  upper  fragment  is  driven  into  the 


Fig.  145. 


Simple  Extracapsular  Frac¬ 
ture  of  the  Neck  of  the  Thigh¬ 
bone:  Detachment  of  the 
Trochanter. 


EXTRACAPS U LAE  FRACTURE  OF  THIGH-BONE.  371 


cancellous  structure  of  the  lower  one,  often  splitting  up  and  detaching 
the  trochanter  (Figs.  146,  14T). 


Section  of  Impacted  Extracapsular  Fractures  of  Xeck  of  Femur;  showing  the  degree  of  Impaction 

and  of  Splintering  in  different  cases. 

The  Signs  of  this  form  of  fracture  are  often  somewhat  negative,  ren¬ 
dering  its  diagnosis  and  detection  extremely  difficult.  There  is  pain 
about  the  hip,  with  eversion  of  the  foot,  sometimes  slight,  sometimes 
great,  and  some  shortening,  occasional!}"  not  more  than  a  quarter  of  an 
inch,  usually  amounting  to  about  half  an  inch,  but  never  exceeding  one 
inch.  There  is  but  little  crepitus — in  some  cases  none  can  be  detected, 
owing  to  the  close  interlocking  of  the  fragments;  and  the  patient  can 
then  raise  the  foot  for  a  few  inches  off  the  couch  on  which  it  is  laid,  and 
even. walk  a  short  distance  upon  it  with  a  hobbling  motion,  though  with 
much  pain.  Some  flattening  over  the  trochanter  is  usually  perceptible  ; 
sometimes  an  increase  in  breadth  from  before  backwards.  In  conse¬ 
quence  of  the  impaction  the  limb  cannot  be  restored  by  traction  to  its 
proper  length,  and  hence  incurable  lameness  always  results  from  this 
injury. 

In  the  extracapsular  fracture  of  the  neck  of  the  femur,  death  not  un- 


Fig.  148. 


Union  in  Impacted  Extracapsular  Frac¬ 
ture  of  Neck  of  Femur. 


Fig.  149. 


Impacted  Extracapsular  Fracture  of 
Neck  of  Femur :  Abundant  Formation 
of  Callus. 


commonly  results  from  the  severity  of  the  injury,  the  pain  and  irritation 
of  the  fracture,  and  the  consequent  shock  to  the  system.  The  great 


372 


SPECIAL  FEACTURES. 


extravasation  of  blood  into  the  tissues  of  the  limb  has  been  known  to 
be  sufficient  to  account  for  the  fatal  result.  When  the  patient  lives, 
bony  union  takes  place,  large  irregular  stalactitic  masses  being  com¬ 
monly  thrown  out  by  the  inferior  fragment,  so  as  to  overlap  the  several 
splinters  of  bone  and  thus  give  the  appearance  of  great  thickening  and 
projection  of  the  trochanter.  This  callus  is  most  abundant  posteriorly 
in  the  intertrochanteric  space  (Fig.  149). 

The  Diagnosis  of  the  different  forms  of  fracture  of  the  neck  of  the 
thigh-bone  from  one  another,  and  from  other  injuries  occurring  in  the 
vicinity  of  the  hip-joint,  is  a  matter  of  considerable  importance,  and 
often  of  no  slight  difficulty.  Between  the  intracapsular  and  the  ordinary 
extracapsulai'  fractures  there  can  be  no  difficulty  ;  all  the  signs  of  the 
latter  being  much  more  strongly  marked  than  those  of  the  former  injury, 
the  difference  of  age  and  the  degree  of  violence  required  to  break  the 
bone  being  also  important  elements  in  the  diagnosis,  as  may  be  seen  by 
the  annexed  Table. 


Diagnosis  between  Intra-  and  Extra-capsular  Fractures  of  the  Neck  of 

the  Thigh f  one. 


Intracapsular. 

1.  Cause  generally  slight  and  indirect, 

such  as  catching  the  foot  in  the  car¬ 
pet  or  slipping  off  the  curb-stone. 

2.  Force  usually  applied  longitudinally 

or  obliquely. 

3.  Age,  rarely  below  fifty ;  most  com¬ 

monly  in  feeble  aged  persons. 

4.  Pain  and  constitutional  disturbance 

slight. 

5.  No  apparent  injury  to  soft  parts  about 

hip. 

6.  Crepitus  often  obscure. 

7.  Shortening  usually  at  first  not  more 

than  one  inch. 


Extracapsular. 

1.  Cause  usually  severe  and  direct  vio¬ 

lence,  such  as  falling  from  a  height 
or  blow  on  hip. 

2.  Force  usually  applied  transversely. 

3.  Age,  usually  below  fifty;  chiefly  in 

vigorous  adults. 

4.  Pain  and  constitutional  disturbance 

usually  considerable. 

5.  Considerable  extravasation,  ecchymo- 

sis,  and  signs  of  direct  injury  to  hip. 

6.  Crepitus  (when  not  impacted)  very 

readily  felt. 

7.  Shortening  (when  not  impacted)  at 

least  two  inches  or  more. 


It  is  more  difficult  to  distinguish  between  the  intracapsular  fracture 
and  the  impacted  extracapsular  fracture.  In  the  former  case,  however, 
the  crepitus  and  eversion  are  more  marked,  and  the  injury  usually 
occurs  from  less  direct  violence  than  when  the  fracture  is  outside  the 
capsule.  In  the  latter  case,  also,  traction  cannot  restore  the  limb  to  its 
proper  length  as  in  the  former  instance. 

Severe  contusions  of  the  hip  are  sometimes  followed  by  eversion  of  the 
limb  with  inability  to  move  it,  so  that  at  first  sight  it  might  be  supposed 
that  the  bone  was  broken.  In  these  cases,  however,  the  absence  of  im¬ 
mediate  shortening  and  crepitus  will  always  establish  the  diagnosis.  But 
though  no  immediate  and  sudden  shortening  can  occur  without  fracture, 
these  contusions  may  be  followed  at  a  remote  period  by  shortening  of  the 
limb  from  atrophic  changes  in  the  head  and  neck  of  the  femur.  When  the 
injured  hip-joint  has  been  the  seat  of  chronic  rheumatic  arthritis.,  and 
the  limb  is  already  somewhat  shortened  before  the  accident,  the  difficulty 
of  diagnosis  becomes  great ;  here,  however,  the  history  of  the  case,  and 
the  fact  of  the  shortening  not  being  of  recent  occurrence,  will  be 
sufficient  to  establish  the  nature  of  the  injuiy.  The  diagnosis  of  these 
injuries  from  dislocations  will  be  considered  in  a  subsequent  chapter. 

The  Treatment  of  the  extracapsular  fracture  may  very  conveniently 
and  efficiently  be  conducted  by  means  of  the  long  splint,  a  padded  belt. 


FRACTURES  OF  SHAFT  OF  THIGH-BONE. 


873 


if  necessary,  being  strapped  firmly  round  the  hips  underneath  it ;  or 
the  plan  recommended  by  Sir  A.  Cooper,  of  placing  the  patient  on  a 
double  inclined  plane,  with  both  feet  and  ankles  tied  together,  and  a  broad 
belt,  well-padded,  firmly  strapped  round  the  body,  so  as  to  press  the 
fragments  of  the  trochanter  firmlj^  against  one  another,  will  be  found  an 
excellent  mode  of  keeping  the  limb  of  a  proper  length,  and  the  frag¬ 
ments  in  contact. 

Occasionally  the  fracture  extends  through  the  trochanter  major  and 
upper  part  of  the  shaft  without  implicating  the  neck  of  the  bone.  Here 
there  is  shortening  to  about  three-fourths  of  an  inch,  or  an  inch,  with 
much  eversion,  and  crepitus  readily  felt.  This  fracture,  which  unites 
firmly  and  w’ell  by  bone,  must  be  treated  in  the  same  way  as  the  last. 

Compound  Fractures  of  the  Neck  of  the  Thigh-bone  can  only  occur 
from  bullet-wounds.  In  these  cases  the  choice  lies  between  amputation 
at  the  hip-joint,  resection  of  the  injured  portion  of  bone,  or  treating  the 
case  as  an  ordinary  compound  fracture.  The  choice  of  the  Surgeon,  for 
reasons  stated  at  p.  202,  lies  between  the  latter  two  alternatives,  which 
are' the  only  ones  that  afford  a  reasonable  hope  of  safety  to  the  patient. 

Fracture  of  the  Trochanter  Major ^  by  which  this  process  is  broken  off 
from  the  rest  of  the  bone,  is  described  by  Nelaton  as  being  always  the 
result  of  direct  violence.  It  may  be  simple  or  comminuted.  The  frag¬ 
ment  is  usually  drawn  upwards  and  backwards,  rarely  forwards ;  and 
more  rarely  it  remains  fixed  by  fibrous  bands  in  its  normal  place.  The 
symi:)toms  are,  separation  between  the  fragments ;  and  crepitus,  which  is 
most  readily  obtained  by  flexing  and  abducting  the  thigh  and  rotating  it 
outwards  at  the  same  time  that  the  fragments  are  firmly  pressed  together. 
There  is  no  shortening  of  the  limb.  The  exact  nature  of  the  injury  is 
often  concealed  b}^  the  swelling  from  extravasated  blood.  The  fracture 
is  very  rare  without  accompanying  fracture  of  the  neck. 

2.  Fractures  of  the  Shaft  of  the  Thigh-bone  are  of  very  common 
occurrence;  every  possible  variety  of  the  injury  being  met  with  here. 
They  are  usually  oblique,  except  in  children,  when  they  are  commonly 
transverse,  and  are  often  comminuted,  double,  or  compound. 

The  Signs  are  well  marked.  There  is  shortening,  usually  to  a  con¬ 
siderable  extent,  with  eversion  of  the  limb,  crepitus  readily  produced, 
and  much  swelling  from  the  approximation  of  the  attachments  of  the 
muscles.  The  lower  fragment  is  always  drawn  to  the  inner  side  of  the 
upper  one,  and  rotated  outwards ;  and  when  the  fracture  is  high  up  there 
is  a  great  tendency  to  angular  deformity,  in  consequence  of  the  pro¬ 
jection  forwards  of  the  lower  end  of  the  upper  fragment.  In  all  cases 
there  is  this  forward  projection,  and  in  most  an  outward  displacement 
as  well  of  tills  fragment.  But  in  some  instances,  though  more  rarely,  it 
is  drawn  inwards  as  well  as  forwards. 

I  have  had  three  opportunities  of  ascertaining  by  dissection  the  con¬ 
dition  of  parts  that  leads  to  the  projection  forwards  and  lateral  displace¬ 
ment  of  the  lower  end  of  the  upper  fragment  in  fracture  of  the  femur. 
The  first  case  was  that  of  an  old  man  who  died  about  three  hours  after 
meeting  with  a  compound  comminuted  fracture  of  the  middle  and  lower 
thirds  of  the  right  thigh-bone,  and  in  whom  eversion  of  the  upper  frag¬ 
ment  was  very  distinctly  marked.  It  was  found  that  the  gluteus  maxi- 
mus  and  medius  could  be  divided  without  afiecting  the  position  of  the 
bone ;  but  when  the  gluteus  minimus  was  cut  across,  it  3nelded  some¬ 
what.  The  p^uuformis  and  external  rotators  were  now  felt  to  be  exces- 
sivel}^  tense ;  and,  on  cutting  these  across,  the  end  of  the  fragment  could 
at  once  be  drawn  inwards,  all  opposition  ceasing.  The  projection  for- 


87-i 


SPECIAL  FRACTUEES. 


wards  still  remained,  however;  and  this,  which  was  evidently  due  to  the 
tension  of  the  psoas  and  iliacus  muscles,  yielded  at  once  on  dividing 
them.  It  would  thus  appear  that  there  must  be  a  double  displacement 
of  the  upper  fragment ;  outwards,  depending  on  the  action  of  the  exter¬ 
nal  rotators ;  and  forwards,  owing  to  the  contraction  of  the  psoas  and 
iliacus  muscles. 

The  second  case  was  one  of  displacement  forwards  and  inwards.  It 
was  that  of  an  elderly  man,  who  died  of  internal  injuries  about  half  an 
hour  after  meeting  with  fracture  of  both  thigh-bones  at  the  junction  of 
the  upper  and  middle  thirds  by  the  passage  of  a  cart-wheel  across  the 
thighs  and  bod}^  In  this  case  nearlj^  the  same  conditions  were  presented 
in  both  limbs.  On  the  left  side  there  was  an  oblique  fracture,  with  short¬ 
ening  to  the  extent  of  about  two  inches ;  the  upper  fragment  was  tilted 
forwards  and  rather  inwards,  the  lower  one  being  drawn  up  behind  it  to 
the  extent  indicated.  On  dividing  the  psoas  and  iliacus,  the  upper  frag¬ 
ment  could  be  depressed  slightly.  The  adductor  brevis  and  pectineus 
were  now  seen  to  be  tense;  on  cutting  them  through,  it  could  be  still 
further  dei^ressed.  It  was  now  drawn  strongl}'-  inwards,  in  consequence 
of  the  extreme  tension  of  the  internal  rotator  muscles  ;  on  cutting  them 
through,  the  fragment  yielded  completely.  Part  of  the  adductor  magnus 
and  of  the  adductor  longus  was  torn.  The  other  muscles  were  unin¬ 
jured.  When  extension  was  made  with  the  limb  straight  out,  the  flexors 
of  the  leg  offered  a  slight  resistance :  they  were  divided.  The  vastus 
externus  was  next  cut  through  ;  the  lower  fragment  could  then  be  drawn 
down  a  quarter  of  an  inch  ;  on  dividing  the  vastus  internus  and  crureus, 
it  yielded  one  inch  more ;  on  cutting  through  the  adductor  magnus  and 
longus,  it  came  down  three-quarters  of  an  inch  more ;  thus  making  up 
the  two  inches  of  shortening.  On  the  right  side,  the  fracture  was  the 
same  as  that  in  the  other  limb.  The  effect  of  the  section  of  the  different 
muscles  was  the  same ;  but  the  vastus  externus  seemed  to  take  a  some¬ 
what  larger  share  in  the  displacement  of  the  lower  fragment. 

The  Treatment  of  fractures  of  the  shaft  of  the  thigh-bone  may  be 
conducted  in  six  different  ways,  each  of  which  presents  advantages  in 
particular  cases;  hence  an  exclusive  plan  of  treatment  should  not  be 
followed. 

Whatever  treatment  is  adopted,  and  however  carefully  it  may  be  car¬ 
ried  out,  the  Surgeon  must  not  be  disappointed  if,  in  the  adult,  a  certain 
amount  of  weakness  be  left.  This  is  more  particularly  the  case  where 
the  fracture  is  oblique  and  high  up :  the  more  transverse  and  the  nearer 
the  cond3des,  on  the  other  hand,  the  less  will  be  the  liabilit}’’  to  shortening. 
In  children,  union  may  almost  always  be  procured  without  any  short¬ 
ening  of  the  bone.  But  a  slight  diminution  in  the  length  of  the  limb  is 
in  reality  of  no  consequence,  and  gives  rise  to  no  inequality  of  gait;  the 
pelvis,  by  the  obliquity'  it  assumes,  remedying  this.  It  is  onl^^  when  the 
shortening  exceeds  half  or  three-quarters  of  an  inch,  that  it  is  important 
and  occasions  deformity. 

I.  The  fracture  may  be  treated  b\'  simply"  relaxing  the  muscles  of  the 
limb.  This  is  effected  by  laying  it  upon  its  outer  side,  flexing  the  thigh 
well  upon  the  abdomen  and  the  leg  upon  the  thigh,  and  supporting  the 
limb  in  this  position  by  an  angular  wooden  or  leather  splint,  extending 
from  the  hip  to  the  knee  or  outer  ankle,  and  by  a  short  inside  thigh- 
splint.  This  position  I  have  occasionally  adopted  in  fractures  about  a 
couple  of  inches  below  the  trochanters,  in  which  there  is  a  great  ten¬ 
dency  to  the  projection  outwards  of  the  lower  end  of  the  upper  fragment, 


FRACTURES  OF  SHAFT  OF  THIGH-BOXE.  875 

and  have  found  these  cases  turn  out  better  in  this  way  than  by  any  other 
plan  of  treatment. 

2.  Extension,  without  regard  to  muscular  relaxation,  by  means  of 
Liston’s  long  splint  and  perineal  band  (Fig.  150),  will  be  found  a  most 


Fig.  150. 


successful  plan  of  treating  fractures  in  the  middle  and  lower  parts  of  the 
thigh. 

In  emplo3dng  the  long  splint  for  the  treatment  of  these  fractures,  care 
must  be  taken  that  it  be  of  sufficient  length  to  extend  about  six  inches 
below  the  sole,  and  nearlv  as  high  as  the  axilla.  The  perineal  band 
consists  of  a  soft  handkerchief  covered  with  oiled  silk,  and  must  be 
graduall}- tightened.  If  the  perineal  band  occasion  excoriation  or  undue 
pressure,  so  as  to  necessitate  its  removal,  I  have  found  advantage  from 
keeping  up  extension  with  a  hea\w  weight  attached  to  the  lower  end  of 
the  splint. 

In  cases  of  compound  fracture,  where  the  aperture  exists  in  the  pos¬ 
terior  and  outer  part  of  the  limb,  I  have  found  a  long  thigh-splint,  made 
of  oak  and  bracketed  opposite  the  seat  of  injuiy,  the  most  convenient 
apparatus,  enabling  the  limb  to  be  kept  of  a  proper  length,  and  the 
wound  to  be  dressed  at  the  same  time  (Fig.  151). 


Fig.  151. 


Compouttd  Fracture  of  Shaft  of  Thigh-bone:  Treatment  by  Bracketed  Long  Splint. 


3.  The  double  inclined  plane  is  especially'  useful  in  many  compound 
fractures  of  the  thigh,  often  admitting  of  greater  facilities  for  dressing 
the  wound  and  the  general  management  of  the  case,  than  any'  other 
apparatus  that  can  be  applied. 

4.  Extension  of  the  limb  by'  the  attachment  of  a  weight  to  the  foot,  a 
plan  of  treatment  employed  by'  James,  of  Exeter,  and  perfected  by  Buck, 
of  New  York,  is  a  most  simple  and  efficient  means  of  treatment.  The 
accompanying  drawing  (Fig.  152)  illustrates  this  well.  The  weight 
recpiired  for  extension  should  vary'  in  the  adult  from  five  to  ten  pounds. 
The  counter-extending  means  consist  of  a  perineal  band,  which  should 
be  of  India-rubber  tubing  properly'  covered  with  muslin  and  fastened  to 
the  head  of  the  bedstead  by'  means  of  straps. 


376 


SPECIAL  FKACTUEES. 


5.  Suspension  of  the  limb  from  a  splint  applied  along  the  anterior 
aspect,  as  in  Fig.  153,  has  been  recommended  by  N.  R.  Smith,  of  Mary- 


Fig.  152. 


land.  As  a  general  plan  of  treatment,  it  is  not  likely  to  be  found 
advantageous.  But  it  is  easy  to  understand  that,  in  certain  cases. 


Fig.  153 


Limb  suspended  from  Splint  by  Slings,  preparatory  to  application  of  Eoller. 


where  injury  was  done  to  the  soft  parts  of  the  limb  posteriorly,  it  might 
be  found  very  useful. 

6.  The  starched  or  plaster  bandage  may  be  employed  in  most  cases. 
In  treating  fractures  of  the  shaft  of  the  thigh-bone  with  the  starched 
bandage,  the  following  plan  will  be  found  convenient.  The  limb  should 
be  evenly  and  thickly  enveloped  in  a  layer  of  cotton  wadding ;  a  long 
piece  of  strong  pasteboard,  about  four  inches  wide,  soaked  in  starch, 
must  next  be  applied  to  the  posterior  part  of  the  limb,  from  the  nates  to 
the  heel.  If  the  patient  be  ver^^  muscular,  and  the  thigh  large,  this  must 
be  strengthened,  especially  at  its  upper  part,  by  having  slips  of  bandage 
pasted  upon  it.  Two  narrower  strips  of  pasteboard  are  now  placed,  one 
along  each  side  of  the  limb,  from  the  hip  to  the  ankle,  and  another 
shorter  piece  on  the  forepart  of  the  thigh.  A  double  layer  of  starched 
bandage  should  now  be  applied  over  the  whole,  with  a  strong  and  well- 
starched  spica.  It  should  be  cut  up  and  trimmed  on  the  second  or  third 
daj’^,  and  then  reapplied  in  the  usual  way.  With  such  an  api^aratus  as 


FEACTURES  NEAR  THE  KNEE-JOINT. 


877 


this  I  have  treated  many  fractured  thighs,  both  in  adults  and  in  children, 
without  confinement  to  the  bed  for  more  than  three  or  four  days,  and 
without  the  slightest  apparent  shortening  or  deformity  being  left  (Fig. 
120).  The  points  to  be  especially  attended  to  are,  that  the  back  paste¬ 
board  splint  be  very  strong,  at  the  upper  part  especially,  and  that  the 
spica  be  well  and  firmly  applied,  so  that  the  hip  and  the  whole  of  the 
pelvis  may  be  immovably  fixed. 

A  simple  comminuted  fracture  of  the  thigh-bone  is  usually  best  treated 
in  the  double  inclined  plane  for  the  first  three  weeks,  after  which  it  may 
be  put  up  in  the  starched  bandage. 

The  Treatment  of  Compound  and  Comminuted  Fracture  of  the  Thigh¬ 
bone  will  vary  according  as  the  injury  arises  from  gunshot,  or  is  an 
accident  of  civil  life.  In  the  former  case,  for  reasons  stated  at  p.  200, 
amputation  should  at  once  be  performed  if  the  fracture  be  below  the 
upper  third  of  the  bone.  When  the  upper  third  is  splintered,  the  result 
of  amputation  is  so  very  unsatisfactory,  that  the  patient  may  have  a 
better  prospect  of  recovery  if  the  limb  be  treated  in  splints,  and  an 
endeavor  made  to  save  it,  disarticulation  at  the  hip-joint  in  such  cases 
being  almost  invariable  fatal. 

When  a  compound,  or  even  a  comminuted  fracture  of  the  thigh-bone, 
occurs  from  one  of  the  common  accidents  of  civil  life,  the  line  of  practice  is 
not  so  defined.  The  course  that  the  Surgeon  adopts  must  be  influenced  by 
the  extent  of  injuiy  done  to  the  soft  parts,  more  particularly  to  the  main 
bloodvessels  of  the  limb.  If  the  integuments  and  muscles  be  extensively 
torn  and  lacerated,  or  if  there  be  reason  to  believe  that  the  femoral 
vessels  have  suffered,  amputation  must  be  practised.  But  if  the  wound 
be  but  small,  made  by  the  perforation  of  the  bone  rather  than  by  the 
violence  which  occasioned  the  fracture,  and  if  the  vessels  be  uninjured, 
an  attempt  must  be  made  to  save  the  limb,  which  should  be  put  up  on 
the  double  inclined  plane  or  in  the  long  bracketed  splints. 

The  treatment  of  the  complication  of  a  luound  of  the  main  artery^ 
femoral  or  popliteal,  with  and  by  a  fracture  of  the  thigh-bone,  will  vary 
according  as  the  injury  is  compound  or  simple.  Such  an  accident, 
complicating  a  compound  fracture,  is  necessarily  a  case  for  immediate 
amputation.  If  the  fracture  be  simple,  and  a  diffused  traumatic  aneurism 
form  in  the  ham  or  lower  part  of  the  thigh,  we  must,  in  accordance  with 
the  principles  laid  down  at  pp.  322-23,  ligature  the  femoral  artery ; 
unless  gangrene  be  supervening,  or  have  actually  supervened,  when  the 
thigh  must  be  amputated  above  the  fracture. 

In  discussing  the  treatment  of  these  accidents,  in  which  the  question 
of  amputation  of  the  thigh  is  raised,  I  cannot  too  strongly  state  my 
conviction  that,  unavoidable  as  it  undoubtedly  is  in  some  cases,  as  the 
only  alternative  left  to  the  Surgeon,  this  operation,  when  practised 
primarily /or  injuries  of  the  thigh-bone  itself^  is  one  of  the  most  fatal  in 
surgery,  and  should  accordingl}^  not  be  too  hastily  resolved  upon. 

3.  Fractures  in  the  Vicinity  of  the  Knee-joint. — The  lower  end  of 
the  thigh-bone  may  be  broken  across  transversely,  through  the  line  of 
junction  between  the  epiph^^ses  and  the  shaft,  both  condyles  being  de¬ 
tached.  This  most  readily  occurs  in  children,  from  the  lower  epiphyses 
not  being  as  yet  solidly  united  to  the  shaft  of  the  bone.  In  other  cases, 
the  fracture  extends  through  one  of  the  condyles,  detaching  it  from  the 
shaft  of  the  bone.  The  readiness  with  which  crepitus  can  be  felt,  the 
line  of  fracture  made  out,  and  the  displacement  removed  by  lateral 
pressure,  determines  at  once  the  nature  of  this  accident. 

When  the  femur  is  fractuted  transversely  immediately  above  the  con- 


378 


SPECIAL  FEACTUEES. 


dyles,  the  lower  fragment  is  powerfully  acted  on  the  gastrocnemius, 
plantaris,  and  popliteus  muscles,  which  flex  it  upon  the  tibia,  causing  its 
upper  extremity  to  project  backwards  into  the  ham,  while  the  lower  end 
of  the  upper  fragment  rests  on  its  anterior  surface.  Thus,  although  the 
limb  may  be  apparently  extended,  the  knee-joint  is  in  reality  flexed.  If 

a  limb  in  this  condition  were  put  up  on  a  long  splint 
and  extension  made,  the  displacement  would  be  in¬ 
creased,  and  non-union  of  the  fracture  would  very 
likely  result ;  or,  if  union  did  occur,  the  utility  of  the 
limb  would  be  most  seriously  impaired.  By  putting 
the  limb  on  a  double  inclined  plane  in  a  flexed  condi¬ 
tion  the  deformity  is  at  once  removed,  the  fractured 
ends  of  the  bones  coming  into  perfect  apposition.  I 
have  had  several  cases  of  impacted  fracture  in  this 
situation  under  my  care.  In  one,  the  upper  fragment, 
which  was  very  oblique,  was  firmly  driven  into  the 
cancellous  structure  of  the  lower  one  (Fig.  154).  In 
another  case,  the  condyles  of  both  thigh-bones  were 
splintered  into  a  number  of  fragments,  amongst  which 
the  shafts  were  impacted.  Excellent  union,  however, 
took  place,  the  skin  having,  been  uninjured.  In  the 

Figs.  155,  156. 


bone.  Fracture  of  Condyles  from  fall  on  tbe  Bent  Knees. 

case  from  which  Figs.  155  and  156  were  taken,  the  patient  fell  from  a 
great  height  on  the  bent  knees.  In  one  knee,  the  anterior  crucial  liga¬ 
ment  had  torn  up  a  piece  of  the  tibia,  to  which  it  was  attached.  In  the 
other,  the  posterior  crucial  ligament  had  torn  out  a  piece  of  the  femur, 
and  the  bone  was  fissured  a  long  way  up  between  the  condyles. 

Fracture  of  the  lower  end  of  the  thigh-bone,  communicating  with  open 
w^ound  of  the  knee-joint,  is  necessarily  a  case  for  amputation. 

Fracture  of  the  Patella  may  be  the  result  of  direct  violence,  when 
the  bone  is  often  comminuted,  or  even  broken  longitudinally,  being  split, 
and  the  joint  possibly  injured.  But  most  frequently  it  occurs  as  the  con¬ 
sequence  of  the  sudden  and  violent  action  of  the  extensor  muscles  of  the 
thigh,  in  the  attempt  a  person  makes  to  save  himself  from  falling  when 
he  suddenly  slips  backwards.  The  knee  being  semi-flexed,  the  patella 
rests  on  it  only  in  its  transverse  axis,  and  is  readily  snapped  across,  much 
in  the  same  way  as  one  breaks  a  stick  across  some  resisting  object. 
All  fractures  of  the  patella  from  muscular  action  are  transverse.  The 
patient  does  not  break  his  patella  in  these  cases  by  falling  upon  it,  but 
he  falls  because  the  patella  has  been  broken  by  the  violent  and  almost 
spasmodic  action  of  the  extensors  of  the  thigh  in  his  efforts  to  save  him¬ 
self.  In  consequence  of  these  fractures  being  occasioned  by  muscular 
action,  they  are  more  frequent  in  men,  especially  about  the  middle  period 


Fig.  154. 


Impacted  Fracture  of 
L  ower  Eud  of  Thigh- 


FRACTUKE  OF  THE  PATELLA. 


879 


of  life,  less  common  in  women,  and  extremely  rare  in  children.  I  have 
once,  however,  had  under  ray  care  a  child  under  ten  years  of  age,  who 
had  a  transverse  fracture  of  the  patella.  It  not  unfrequently  happens 
when  one  patella  has  been  fractured,  that  the  unsteadiness  of  gait  causes 
the  opposite  one  to  be  broken  b}^  muscular  action  in  an  effort  to  save  a 
fall.  The  same  patella  maybe  broken  more  than  once;  in  the  cases  that 
I  have  seen,  the  second  fracture  has  always  occurred  in  the  upper  frag¬ 
ment,  a  little  above  the  line  of  the  original  fracture. 

The  Signs  of  this  fracture  are  very  evident.  When  it  is  transverse, 
and  has  been  produced  by  muscular  action,  the  librous  expansion  over 
the  bone  is  torn;  and  the  separation  between  the  fragments  (Fig.  15 
which  is  much  increased  by  bending  the  knee  (Fig.  158),  and  the  inability 
to  stand  or  to  raise  the  injured  limb,  indicate  what  has 
happened.  When  it  has  been  produced  by  direct  vio-  Fig.  157. 
lence,  the  muscles  being  at  rest,  there  is  little  or  no 
separation,  even  though  the  fracture  be  transverse. 

In  such  cases,  and  when  it  is  longitudinal  or  com¬ 
minuted,  the  crepitus  and  mobility  of  the  fragments 


Fig.  158. 


Fracture  of  Patella ;  Separation  between  Fragments  increased  Fractured  Patella  ;  Side  view 
by  bending  the  Knee.  of  Limb,  straight. 


point  it  out ;  and  there  is  usually  considerable  swelling  of  the  knee- 
joint,  with,  perhaps,  wound  of  it. 

3Iode  of  Union. — When  the  bone  is  broken  transversely,  it  very  rarely 
indeed  unites  by  osseous  matter,  in  consequence  of  the  wide  separation  of 
the  fragments  ;  there  are,  however,  two  or  three  cases  on  record  in  which 
this  kind  of  union  has  taken  place  in  these  fractures.  In  the  longitudinal 
and  comminuted  fractures,  osseous  union  readilj^  occurs,  the  fragments 
remaining  in  close  apposition.  In  the  majoritj’  of  cases  of  transverse  frac¬ 
ture,  the  fragments  remain  separated  by  an  interval  varying  from  one- 
fourth  of  an  inch  to  an  inch ;  but  in  some  instances  the  gap  is  much 
greater,  amounting  even  to  four  or  five  inches.  When  the  separation  does 
not  exceed  an  inch  and  a  half,  the  gap  is  usually  filled  up  by  fibrous  or  liga- 
mentous.tissue,  uniting  the  fragments  firml}^  In  some  of  the  cases,  how¬ 
ever,  in  which  the  separation  between  the  fragments  does  not  exceed  this 
distance,  and  in  most  of  those  in  which  it  extends  beyond  it,  W.  Adams  has 
found  that  the  fracture  is  not  united  by  any  plastic  matter  that  has  been 
thrown  out,  but  that  the  fragments  are  bound  together  simply  by  the  thick¬ 
ened  fascia  which  passes  over  the  patella,  with  which  is  incorporated  the 
bursa  patellm.  Adams  finds  that  the  aponeurotic  structure  thus  uniting 
the  fragments  may  be  arranged  in  different  ways.  Thus  it  may  pass  be- 


380 


SPECIAL  FRACTURES. 


tween  the  fragments,  and  be  adherent  to  the  anterior  periosteal  surface  of 
both ;  or  the  connectingaponeurosis  ma3^be  reflected  over,  and  be  adherent 
to  both  the  fractured  surfaces  ;  or,  lastl}^  (and  this  is  the  most  frequent 
form  of  arrangement),  the  connecting  aponeurosis  may  pass  from  the  peri¬ 
osteal  surface  of  the  upper  fragment  to  the  fractured  surface  of  the  lower 
one,  to  which  it  becomes  closel}"  and  firml}^  united.  In  the  majorit}’  of 
cases,  when  united  b}^  aponeurotic  tissue,  the  fragments  gape  somewhat 
towards  the  skin,  coming  into  better  conduct  posteriori}'.  Thus,  it 
would  appear  that  a  patella  fractured  transversel}'  maj'  unite  in  two  waj’^s ; 
most  frequentl}'  b}’  the  intervention  of  thickened  aponeurotic  structure, 
and  next,  by  a  ligamentous  or  fibrous  band.  Of  31  specimens  in  the 
London  museums,  examined  b}’’  Adams,  it  was  found  that  in  15  aponeu¬ 
rotic  union  had  taken  place,  in  12  ligamentous  union,  and  in  the  remain¬ 
ing  4  the  kind  of  union  could  not  be  determined. 

The  aponeurotic  union  alwa3's  leaves  a  weakened  limb  and  an  unpro¬ 
tected  joint;  for,  in  consequence  of  the  separation  of  the  fragments,  the 
folding  in  of  the  fascia,  and  its  adhesion  to  the  capsule  of  the  joint,  the 
fingers  can  be  thrust  in  between  the  articular  surfaces  of  the  knee. 

Treatment. — In  many  cases  of  fractured  patella,  there  is  rather  severe 
inflammatoiy  action  in  the  knee,  with  great  s3movial  effusion.  This 
requires  to  be  reduced  b}"  rest  and  the  application  of  evaporating  lotions, 
before  an}'  other  treatment  can  be  adopted.  When  this  has  been  eflected, 
means  must  be  taken  for  the  union  of  the  fragments ;  with  this  view, 
the  principal  point  to  be  attended  to  is  to  keep  them  in  sufficient!}'  close 
apposition  for  firm  ligamentous  union  to  take  place.  With  this  view, 
the  upper  fragment,  which  is  movable,  and  has  been  retracted  by  the 
extensor  muscles  of  the  thigh,  must  be  drawn  down  so  as  to  be  approx¬ 
imated  to  the  lower  one,  which  is  fixed  by  the  ligamentum  patellae.  This 
approximation  of  the  fragments  may  be  effected  either  by  position  and 
relaxation  of  the  muscles,  or  by  mechanical  contrivance.  Simple  posi¬ 
tion  usually  suffices  for  this  purpose,  and  must  be  attended  to  whatever 
mechanical  appliances  are  used.  By  placing  the  patient  in  a  semi-recum¬ 
bent  position,  and  elevating  the  leg  considerably,  so  as  to  relax  the 
muscles  of  the  thigh  completely,  the  upper  fragment  may  be  brought 
down  to  the  lower  one,  and,  if  necessary,  may  be  retained  there,  after 
any  local  inflammation  that  results  from  the  accident  has  been  subdued, 
by  moulding  a  gutta-percha  cap  accurately  to  and  fixing  it  firmly  upon 
the  knee,  or  by  the  application  of  pads  of  lint  and  broad  straps  of  plas¬ 
ter.  These  straps  of  plaster  may  be  applied  above  and  upon  the  upper 
fragment  in  a  diagonal  direction  from  above  downwards.  They  should 
be  of  sufficient  length  to  embrace  the  limb  and  the  back  splint,  to  which 
they  are  to  be  fixed,  or  a  figure-of-8  bandage  may  be  applied  round  the 
limb  and  splint  together.  This  position  must  be  maintained  for  at  least 
six  weeks ;  at  the  expiration  of  which  time  the  patient  may  be  allowed 
to  walk  about,  wearing,  however,  an  elastic  knee-cap,  or,  what  is  better, 
a  straight  leather  splint  in  the  ham,  so  as  to  prevent  the  knee  from  being 
bent  for  at  least  three  months.  If  this  precaution  be  not  taken,  the 
union  between  the  fragments,  which  at  first  appear  to  be  in  very  close 
contact,  will  graduallv  lengthen,  until  in  the  course  of  a  few  months  an 
interval  of  several  inches  may  be  found  between  them.  In  these  cases, 
however,  even  though  the  separation  between  the  fragments  be  great, 
it  is  remarkable  how  well  the  limb  may  be  used,  especially  on  level 
ground ;  and  with  the  aid  of  a  knee-cap  but  little  inconvenience  is  expe¬ 
rienced  by  the  patient. 

In  most  cases  of  fractured  patella  the  starched  bandage  will  be  found 


TREATMENT  OF  FRACTURED  PATELLA. 


881 


very  useful,  the  patient  being  with  it  enabled  to  walk  about  during  the 
whole  of  the  treatment.  The  action  of  the  bandage  is  much  increased 
Dy  drawing  down  and  fixing  the  upper  fragment  by  two  broad  strips  of 
plaster  firmly  applied  above  it.  A-  back  splint  of  pasteboard  is  required 
to  fix  the  knee,  and  a  good  pad  of  lint  with  a  figure-of-8  bandage  should 
be  applied  above  and  below  the  fracture  to  keep  it  in  position.  In  several 
cases  I  have  obtained  very  close  and  firm  union  between  the  fragments 
in  this  way,  without  confining  the  patient  to  bed  after  the  third  day,  and 
now  seldom  employ  any  other  method  of  treatment. 

Yarious  attempts  have  at  different  times  been  made  to  bring  down 
and  to  fix  the  upper  fragment,  so  as  to  keep  it  in  contact  with  the  lower 
one ;  or,  if  this  be  impracticable,  to  shorten  the  distance  between  them, 
and  thus  to  lessen  the  length  of  the  bond  of  union.  With  this  view,  an 
apparatus  consisting  of  two  broad  bands  of  leather,  buckled  above  and 
below  the  knee,  and  united  by  longitudinal  straps,  which  can  be  short¬ 
ened  at  pleasure,  is  very  commonly  employed.  Malgaigne,  with  the 
same  view,  constructed  a  pair  of  double  hooks,  which,  being  fixed  into 
the  two  fragments,  were  drawn  together  b}^  a  screw ;  and  Eve,  of  Ten¬ 
nessee,  accomplishes  the  same  object  by  means  of  a  ring  passed  round 
the  fragments.  All  these  means  undoubtedly  secure  the  object  for  which 
they  are  intended,  and  each  may  be  found  an  useful  adjunct  to  position 
in  any  given  case.  Malgaigne’s  hooks  are  undoubtedly  the  most  efectual ; 
but  the  great  objection  to  their  use  consists  in  the  pain  and  irritation 
that  are  often  induced  by  their  penetration  of  the  skin. 

Stiffness  of  the  knee  often  remains  to  a  very  inconvenient  degree  after 
the  treatment  of  a  fractured  petella.  It  is  usually  remedied  by  friction 
and  manipulation.  But  should  it  not  yield  to  these  minor  means,  an 
apparatus  consisting  of  a  thigh  and  leg  piece  of  stiff  leather,  united  by 
angularly  hinged  lateral  iron  rods,  and  having  an  India-rubber  “  accu¬ 
mulator  ”  adapted  behind,  should  be ’worn.  The  continued  traction  of 
the  “  accumulator  ”  will  gradually  flex  the  knee.  But,  as  the  knee 
becomes  bent,  the  close  union  that  may  have  appeared  to  exist  between 
the  fragments  gradually  yields,  and  they  gape  more  or  less  widely,  much 
to  the  disappointment  often  of  both  Surgeon  and  patient,  the  ligamen¬ 
tous  band  stretching  like  a  piece  of  vulcanized  India-rubber.  This  can¬ 
not  be  helped.  There  is  the  alternative  between  a  straight  and  stiff 
knee  with  close  union,  or  a  flexible  and  mobile  one  with  gaping  of  the 
fragments.  After  the  knee  is  flexible,  lateral  hinged  splints  may  be 
worn  without  the  elastic  strap.  The  limb  that  exists  is  usually  perfectly 
strong,  and  good  for  any  exercise  except  jumping. 

In  Simple  Comminuted  Fractures  of  the  Patella^  the  result  of  direct 
blows  or  kicks,  the  fragments  are  not  much  separated,  and  union  takes 
place  readily  by  bone.  In  these  cases,  after  subduing  inflammatory 
action,  which  usually  runs  high,  the  starched  bandage  may  be  applied, 
and  the  knee  and  fragments  thus  both  kept  immovable. 

Compound  and  Comminuted  Fractures  of  the  Patella^  especially  if 
occasioned  b}^  bullet-wounds,  and  opening  the  knee-joint,  are  cases  for 
immediate  amputation. 

Necrosis  of  the  Patella  as  the  result  of  fracture  is  rare.  In  one  such 
case  which  was  under  my  care  at  the  Hospital,  the  patient,  a  middle- 
aged  man,  had  met  with  an  ordinary  transverse  fracture  of  the  patella, 
which  united  by  ligament  two  years  after  the  accident ;  and  without  any 
fresh  injury  he  came  to  the  Hospital,  with  necrosis  of  the  outer  half 
of  the  upper  fragment,  which  was  completely  detached,  and  lying  in  a 
cavity  bounded  and  shut  ofi*  from  the  joint  by  plastic  matter.  I  cut 


882 


SPECIAL  FRACTURES. 


down  upon  and  removed  the  necrosed  fragment,  wliich  appeared  to  con¬ 
stitute  about  one-quarter  of  the  patella.  No  cause  could  be  assignee} 
for  the  necrosis,  except  defective  vascular  supply  to  this  part  of  the 
bone. 

Fractures  of  the  Bones  of  the  Leg. — The  bones  of  the  leg  are 
frequently  broken.  The  tibia,  though  a  stronger  bone  than  the  fibula, 
is  most  frequently  fractured,  owing  to  its  being  more  exposed  and  less 
protected  by  muscles,  and  receiving  more  directly  all  shocks  communi¬ 
cated  to  the  heel.  The  fractures  of  the  upper  part  of  this  bone  are 
usually  transverse,  and  result  from  direct  violence ;  those  of  the  lower 
part  are  oblique,  and  proceed  from  indirect  violence.  When  both  bones 
are  broken,  the  usual  signs  of  fracture,  such  as  shortening,  increased 
mobility  at  the  seat  of  injury,  and  crepitus,  render  the  diagnosis  eas}^ ; 
but  when  one  bone  alone  is  broken,  it  is  not  ahvays  a  very  simple  matter 
to  determine  the  existence  of  the  fracture ;  the  sound  bone,  acting  as  a 
splint,  prevents  displacement,  and  keeps  the  limb  of  a  proper  length  and 
steady.  If  it  be  the  tibia  alone  that  has  been  broken,  the  fracture  may 
be  detected  by  running  the  finger  along  the  subcutaneous  edge,  until  it 
comes  to  a  point  that  is  somewhat  irregular,  puffy,  or  tender,  where  by 
accurate  examination  some  mobility  and  slight  crepitus  may  be  detected. 
When  the  fibula  alone  is  broken,  the  thick  layer  of  the  peroneal  muscles, 
overlaying  its  upper  two-thirds,  renders  the  detection  of  the  fracture 
difficult  5  but  in  the  lower  third  it  is  easy,  by  attention  to  the  same  signs 
that  occur  in  fractured  tibia. 

In  the  Treatment  of  simple  Uncomplicated  Fractures  of  the  Leg  every 
possible  kind  of  apparatus  has  been  used.  In  the  majority  of  cases, 
where  there  is  but  little  displacement  and  swelling,  ordinary  leg-splints 
(Cline’s,  well  padded,  are  extremely  convenient)  are  readily  applied  and 
keep  the  bones  in  good  apposition.  These  may  be  kept  on  for  the  first 
few  days  and  then  replaced  hy  the  starched  or  plaster  bandage.  In 
fracture  of  the  leg,  indeed,  the  starched  bandage  is  especially  applicable. 
It  should  be  applied  as  follow's.  The  limb  having  been  well  covered  writh 
w^adding,  a  strong  soaked  pasteboard  splint,  four  inches  broad,  and  long 
enough  to  extend  from  above  the  knee  to  six  or  eight  inches  beyond  the 
heel,  should  be  applied  to  the  back  of  the  leg.  The  projecting  terminal 


Fig.  159. 


piece  is  now  to  be  turned  up  along  the  sole  of  the  foot,  and  two  lateral 
strips  adapted,  one  to  each  side  of  the  limb.  Over  tliis  the  starched 
,  bandage,  single  or  double  according  to  the  size  of  the  limb,  must  be 


TREATMENT  OF  SIMPLE  FRACTURE  OF  LEG. 


383 


tightly  applied.  After  it  is  dry,  about  the  end  of  the  second  da}^,  it 
must  be  cut  up  as  represented  in  Fig.  122,  and  readjusted,  and  the  patient 
may  then  walk  on  crutches  with  perfect  safety.  M’Intyre’s  splint  (Fig. 
159)  will  be  found  of  great  service  in  the  earlier  periods,  if  there  be  much 
ecchymosis  or  extravasation,  as  it  keeps  the  limb  in  an  easy  position, 
and  allows  the  ready  application  of  evaporating  lotions.  In  applying 
this  splint,  there  are  four  points  that  require  to  be  attended  to;  1.  That 
the  angle  be  convenient,  and  suitable  to  the  apposition  of  the  fragments  ; 

2.  That  the  aperture  corresponding  to  the  heel  be  closed  by  a  few  turns 
of  a  roller  in  which  the  heel  may  rest  firmly,  but  with  a  certain  amount 
of  yielding  pressure  ;  3.  That  the  foot  be  covered  with  a  flannel  sock  : 
and,  4.  That  the  foot-piece  be  raised  and  steadied  on  a  wooden  block. 
In  some  cases  of  fracture  of  the  bones  of  the  leg,  however,  M’Intyre’s 
apparatus  is  not  applicable.  This  is  more  particular!}^  the  case  when 
the  fracture  is  very  oblique,  from  above  downwards,  and  from  before 
backwards  ;  in  these  circumstances,  the  fragments  cannot  be  brought 
into  good  position  so  long  as  the  limb  is  kept  extended  and  resting  on 
its  posterior  surface ;  the  bones  riding  considerably,  and  one  or  other 
of  the  fractured  ends  pressing  upon  the  skin  in  such  a  way  as  often  to 
threaten  ulceration.  In  these  cases  it  is,  that  division  of  the  tendo 
Achillis  has  been  recommended,  with  a  view  of  removing  the  influence 
of  muscular  contraction.  This  appears  to  me,  however,  to  be  an  unne¬ 
cessarily  severe  procedure,  and  certainl}^  was  not  very  successful  in  some 
cases  in  which  I  have  practised  it;  for,  although  the  tendon  was  exceed¬ 
ingly  tense,  but  temporary  benefit  resulted,  the  displacement  returning 
under  the  influence  of  the  other  muscles  inserted  into  the  foot.  In  these 
cases  the  bones  may  usually  be  brought  into  excellent  position  by  flexing 
the  thigh  well  up  the  abdomen,  and  the  leg  upon  the  thigh,  so  that  the 
heel  nearly  touches  the  nates,  and  then  laying  the  limb  on  its  outer  side 
on  a  wooden*  leg-splint,  provided  with  a  proper  foot-piece,  and  keeping 
it  fixed  in  this  position.  In  some  cases  the  swing-box  (Fig.  160)  will  be 
found  a  useful  and  very  easy  apparatus.  In  some  fractures  of  the  leg,  the 
lower  end  of  the  upper 
fragment  projects  consi¬ 
derably,  and  cannot  be 
brought  into  proper  posi¬ 
tion  so  long  as  the  knee 
is  kept  bent ;  but  if  it  be 
extended,  so  as  to  relax 
the  extensors  of  the  thigh, 
the  bone  is  readily  brought 
into  good  position.  In 
fractures  of  the  leg,  as  in 
all  injuries  of  a  similar 
kind,  no  one  plan  of  treat¬ 
ment  should  be  adopted 
exclusively, but  the  means 
employed  should  be  varied 
and  suited  according  to 
the  peculiarities  of  each 
individual  case. 

In  the  management  of  all  fractures  of  the  tibia,  the  foot  should  be 
carefully  kept  as  nearly  as  possible  at  right  angles  to  the  leg.  If  it  be 
allowed  to  drop,  so  that  the  toes  point,  there  will  be  a  tendency  for  the 
astragalus  to  slip  forwards  from  under  the  malleolar  arch  ;  the  ankle-  , 


884 


SPECIAL  FRACTUEES. 


joint  being  thus  permanently  weakened  by  the  elongation  of  its  anterior 
ligament. 

For  the  treatment  of  Complications  of  Simple  Fracture  of  the  Leg^  see 
pp.  322,  et  seq. 

Compound  Fractures  of  the  Tibia  are  of  more  frequent  occurrence 
than  similar  injuries  of  any  other  bone  in  the  body.  This  is  owing  to 
the  thin  covering  of  soft  parts  over  the  anterior  and  inner  aspect  of 
the  bone,  and  to  the  fact  of  its  fracture  being  usuall3"  oblique ;  so  that 
the  sharply  pointed  end  of  the  upper  fragment  is  liable  to  be  thrust 
through  the  integument,  when  the  lower  part  of  the  limb  falls  backwards 
as  the  injured  person  is  being  raised  off  the  ground.  The  fracture  ma}’’, 
of  course,  also  be  rendered  compound  by  the  same  direct  violence  that 
breaks  the  bone. 

The  Treatment  and  probable  result  of  the  case  will  in  a  great  mea¬ 
sure  depend  upon  the  waj^  in  which  the  fracture  has  been  rendered  com¬ 
pound,  and  on  the  amount  of  the  laceration  and  contusion  of  the  integu¬ 
ments.  When  the  wound  in  the  integuments  is  the  result  of  their 
transfixion  b}"  the  point  of  the  upper  fragment,  it  may  commonl}’-  be 
closed  b}"  the  first  intention,  b}^  la^fing  over  it  a  piece  of  lint  soaked  in 
blood  or  in  collodion,  or  using  Lister’s  carbolic  acid  dressing,  after 
reduction  has  been  effected,  and  the  limb  put  on  a  M’Intju’e’s  splint,  the 
lint  being  left  undisturbed  as  long  as  possible.  Or  the  limb  maj-  be  put 
up  in  a  starched  bandage,  in  which  a  trap  is  cut  to  allow  the  dressing  of 
the  wound,  as  represented  in  Fig.  123.  Should  there  be  difficult}^  in 
preventing  the  protrusion  or  in  effecting  the  reduction  of  the  pointed 
fragment,  this  must  be  cleanl}-  sawn  oflT  or  the  wound  be  enlarged  so  as 
to  sink  it,  as  directed  at  p.  329. 

In  the  event  of  there  being  great  contusion  and  laceration  of  the  soft 
parts,  as  when  the  fracture  is  rendered  compound  by  a  wagon-wheel 
passing  over  the  leg,  it  is  useless  to  adopt  the  routine  practice  of  at¬ 
tempting  to  close  the  wound  b}-  la3fing  over  it  a  piece  of  lint  soaked  in 
blood  or  collodion.  It  cannot  unite,  as  in  the  other  case,  by  the  first 
intention.  Suppuration  must  take  place,  and  this  is  best  met  with  at 
once  b3^  the  application  of  water-dressing  after  reduction.  Indeed,  in 
cases  of  this  kind,  the  greatest  danger  results  to  the  patient  from  the 
Surgeon  plastering  the  wound  over  with  a  piece  of  lint  rendered  hard 
and  impervious  b3"  dried  blood,  or  attempting  its  closure  in  an3’'  other 
wa3\  The  inflammatoiy  discharges  are  prevented  from  escaping ;  and 
unhealtln^  pus  or  broken  down  blood  accumulates  in  the  limb,  which 
becomes  greath^  swollen,  tense,  red,  painful,  and  hot.  The  patient 
becomes  restless ;  high  irritative  fever  is  set  up ;  and,  unless  relief  be 
given  b3'  the  evacuation  of  the  pent-up  discharges,  b3^  opening  up  the 
wounds  freel3’,  and  perhaps  hy  L’ee  incisions  and  counter-openings  as 
well,  the  worst  form  of  p3’8emia  will  almost  inevitabl3’’  ensue. 

If  the  tibia  be  much  comminuted  and  the  fracture  compound,  the  case 
is  usuall3'  one  for  amputation  ;  but  should  the  patient  be  3'oung  and 
vigorous,  an  attempt  even  in  such  cases  ma3'  be  made  to  save  the  limb. 
Here  a  good  deal  ma3"  be  done  in  the  wa3’’  of  picking  out  detached 
splinters  of  bone,  and  sawing  off*  smoothl3"  the  jagged  and  pointed  ends 
of  the  adherent  fragments.  The  length  of  the  tibia  will  thus  be  lessened, 
and  the  patient  will  recover  with  a  necessaril3"  shortened,  but  otherwise 
firm  and  useful  limb.  Care  must  be  taken  in  the  after-treatment  of  such 
cases  that  too  effective  extension  be  not  kept  up,  lest  a  gap  be  left 
between  the  fractured  ends,  which  cannot  be  filled  up  with  callus  ;  the 


FRACTURES  IN  VICINITY  OF  ANKLE-JOINT. 


885 


consequence  being  that,  in  the  attempt  to  obtain  good  length  of  limb, 
want  or  imperfection  of  consolidation  results. 

In  both  the  last  classes  of  cases,  tension  of  the  limb  from  deep 
abscess,  possibly  requiring  incision,  may  ensue ;  or  the  consolidation  of 
the  fracture  and  the  healing  of  the  wound  be  retarded  by  necrosis  of 
some  of  the  splinters,  or  of  the  extremity  of  one  of  the  fragments, 
generally  the  lower  one;  and  not  unfrequently,  after  a  proper  but  unsuc¬ 
cessful  attempt  to  save  the  limb,  the  profuseness  of  the  suppuration  and 
the  amount  of  constitutional  debility,  may  render  imperative  secondary 
amputation  above,  at,  or  below  the  knee. 

Hemorrhage  is  a  common  complication  of  compound  fractures  of  the 
leg.  When  venous  and  moderate  in  quantity,  it  may  be  arrested  by 
position  and  cold.  When  arterial  and  abundant,  proceeding  from  lace¬ 
ration  of  one  of  the  tibials,  the  line  of  practice  to  be  adopted  must  to  a 
great  extent  be  determined  by  the  situation  of  the  fracture,  and  of  the 
concomitant  arterial  wound.  If  these  be  anywhere  above  the  lower  third 
of  the  limb,  it  is  useless  for  the  Surgeon  to  attempt  to  secure  the  bleeding 
vessels  by  groping  amongst  and  under  the  deep  muscles  of  the  limb, 
infiltrated  and  disorganized  as  they  are  by  the  injury  and  by  extrava¬ 
sation.  It  is  equally  futile,  in  these  cases,  to  ligature  the  superficial 
femoral  artery.  Such  an  operation  either  fails  in  arresting  the  hemor¬ 
rhage,  or,  if  it  stop  the  circulation  sufficiently  for  this,  gives  rise  to  gan¬ 
grene.  There  is,  consequently,  no  resource  but  amputation  ;  and  the 
sooner  this  is  practised,  the  better  will  be  the  patient’s  chance  of 
recovery.  If,  however,  the  fracture  be  situated  and  the  artery  be  torn 
low  down  in  the  limb,  where  the  vessels  are  superficial,  and  more  espe¬ 
cially  if  the  injury  be  near  the  ankle-joint,  an  attempt  might  be  made — 
provided  other  circumstances  were  favorable — to  appl}^  a  ligature  to  the 
bleeding  artery,  and  thus  to  save  the  limb.  This  would  be  more  feasible 
with  wound  of  the  anterior  than  of  the  posterior  tibial  artery. 

Fractures  in  the  Vicinity  of  the  Ankle-joint  are  amongst  the  most 
common  injuries  of  the  bones  of  the  lower  extremit3^  They  are  usually 
occasioned  by  twists  of  the  foot,  by  catching  it  in  a  hole  whilst  running, 
b}"  jumping  from  a  height  to  the  ground,  or  off  a  carriage  in  rapid 
motion.  These  fractures  are  usually  associated  with  severe  strain,  or 
even  dislocation,  of  the  ankle.  Twist  of  the  foot 
in  these  cases  must  not  be  confounded  with  dislo¬ 
cations  of  the  ankle.  In  a  twist  the  foot  carries 
with  it  the  lower  fragments  of  the  leg-bones,  and 
the  malleolar  arch  in  a  more  or  less  perfect  state. 

In  a  dislocation,  the  foot  is  thrown  out  from  under 
this  arch.  The  twist  of  the  foot  is  almost  invariably 
outwards,  with  the  inner  side  downwards  and  the 
outer  edge  turned  up,  or  the  sole  remaining  in  this 
direction,  though  not  always  to  the  extent  that 
Dupuytren  states,  and  the  inner  melleolus  projecting 
under  the  skin.  Most  commonly  the  toes  are  turned 
somewhat  out,  and  the  heel  in. 

Fractures  of  the  lower  ends  of  the  tibia  and  fibula 
present  four  distinct  varieties  in  degree. 

1.  The  fibula  may  be  broken  two  or  three  inches 
above  the  malleolus  externus,  the  deltoid  ligament 
being  either  stretched  or  torn. 

2.  The  fibula  ma^’'  be  fractured  about  three  inches 
above  the  ankle,  the  tip  of  the  malleolus  internus  being  splintered  off 

VOL.  I. — 25 


Fig.  161. 


Fractures  of  Tibia  and 
Fibula  above  Ankle. 


886 


SPECIAL  FRACTUEES. 


as  well.  This  constitutes  the  form  of  injur}’-  called  PoWs  Fracture^  and 
is  perhaps  the  most  common  fracture  in  this  situation. 

3.  The  fibula  may  be  fractured  about  three  inches  above  the  ankle,  and 
the  lower  end  of  the  tibia  at  the  same  time  be  splintered  ofi*  in  an  oblique 
direction  from  without  downwards  and  inwards  (Fig.  161). 

4.  The  internal  malleolus  may  alone  be  broken  ofi*,  the  fibula  remaining 
sound,  but  one  of  the  divisions  of  the  external  lateral  ligament  being 
torn  through. 

The  Signs  of  these  fractures  vary  somewhat  according  to  the  bone 
that  is  injured.  When  the  fibula  alone  is  broken,  there  is  but  slight 
displacement  of  the  foot,  but  great  pain  and  much  swelling,  with  per¬ 
haps  indistinct  crepitus,  and  irregularity  of  outline  at  the  seat  of  frac¬ 
ture.  When  the  lower  j^art  of  the  fibula  is  broken,  pain  is  produced  at 
the  fractured  j^art  by  squeezing  the  bones  of  the  leg  together  at  a  point 
distant  from  the  seat  of  injury.  If  the  tip  of  the  inner  malleolus  be 
broken  ofi^  as  well,  this  may  be  ascertained  by  feeling  the  depression 
above  the  detached  fragment.  In  those  cases  the  crepitus  is  more  dis¬ 
tinct,  and  the  displacement  of  the  foot  is  much  more  marked,  the  sole 
being  turned  somewhat  upwards  and  outwards,  and  the  patient  resting 
upon  its  inner  side.  It  is  this  peculiar  twist  of  the  foot  with  its  outer 
edge  turned  up,  and  the  inner  side  down,  that  constitutes  the  charac¬ 
teristic  sign  of  Pott’s  fracture.  In  those  cases  in  which  the  lower  end 
of  the  tibia  is  obliquely  splintered,  as  well  as  the  fibula  broken,  there  are 
not  only  the  ordinary  signs  of  fracture,  with  eversion  of  the  toes,  and 
a  corresponding  turning  inwards  of  the  heel,  and  some  rotation  of  the 
foot  outwards,  but  the  malleoli  are  widely  separated,  giving  an  appear¬ 
ance  of  great  increase  of  breadth  to  the  joint;  crepitus  is  very  readily 
felt,  and  a  depression  can  be  perceived  corresponding  to  the  line  of 
fracture. 

The  Treatment  of  these  cases  is  always  fraught  with  difficulty.  In 
consequence  of  the  swelling  and  infiammation  that  usually  occur,  it  is 
often  difficult  to  make  out  the  exact  extent  and  direction  of  the  fracture. 
This  difficulty  is  greatly  increased  by  the  small  size  and  short  leverage 
afforded  by  the  fragments ;  and  so  great  is  it,  that  in  some  cases  it 
cannot  be  overcome  by  any  amount  of  skill  and  patience  that  may  be 
brought  to  bear  on  the  treatment  of  the  injury,  but  a  certain  degree  of 
displacement  results  as  the  necessary  consequence  of  the  injury,  leaving 
a  weak  and  painful  joint,  the  mobility  of  which  is  seriously  impaired. 

If,  as  usually  happens,  more  particularly  when  the  fracture  results 
from  direct  violence,  there  be  a  good  deal  of  swelling  from  ecchymosis 
and  inflammatory  action,  this  will  require  to  be  subdued  by  the  con¬ 
tinuous  application  of  cold,  and  the  limb  should  be  laid  on  a  splint.  If 
there  be  not  much  displacement  of  the  foot,  the  treatment  may  best  be 
conducted  by  splints  with  good  foot-pieces,  and  the  starched  bandage. 
When  there  is  no  twist  of  the  foot,  perhaps  the  best  apparatus  is  a 
MTntyre’s  splint ;  or  the  limb  may  be  put  up  in  lateral-leg-splints,  with 
good  foot-pieces,  and  swung  in  a  cradle.  Whatever  apparatus  is  used, 
care  must  be  taken  to  keep  the  sole  of  the  foot  nearly  at  a  right  angle 
with  the  leg.  If  the  toes  be  allowed  to  point,  it  will  be  found  that 
there  is  in  some  cases  a  tendency  for  the  astragalus  to  roll  forwards,  as 
it  were  from  under  the  malleolar  arch.  In  other  instances,  again,  one 
of  the  sharp  angular  fragments  connected  with  the  bone  may  be  pressed 
forwards,  and,  uniting  in  this  position,  give  rise  to  permanent  deformity. 
But  whatever  care  be  employed,  or  apparatus  applied,  it  will  be  found 
impossible  in  some  cases  to  replace  one  of  the  thin  angular  fragments. 


FRACTURES  NEAR  THE  ANKLE-JOINT. 


387 


if  it  become  twisted  on  its  axis,  and  project  sharply  under  the  skin.  If 
the  foot  be  much  twisted  outwards,  as  often  happens  in  Pott’s  fracture, 
Dupu3'treu’s  splint  should  be  applied  to  the  inner  side  of  the  limb,  so  as' 
to  counteract  the  displacement  (Fig  162).  In  applying  the  apparatus, 
three  points  require  attention.  1.  The  pad  should  be  folded  double  at 
the  lower  end,  and  not  descend  below  the  ankle,  so  as  to  form  a  fulcrum. 


Pott’s  Fracture  :  application  of  Dupuytren’s  Splint. 


across  which  the  foot  may  be  drawn  to  the  inner  side.  2.  The  bandage 
should  not  be  carried  above  the  knee,  but  terminate  just  below  the 
flexure  of  the  joint.  3.  The  knee  should  be  bent,  so  as  to  flex  the  leg  or 
the  thigh,  and  thus  to  relax  the  strong  muscles  of  the  calf,  which,  by 
drawing  up  the  heel,  and  causing  the  toes  to  point,  offer  a  serious 
obstacle  to  the  maintenance  of  the  foot  in  a  good  position.  Much  stiff¬ 
ness  is  always  left  after  union  has  taken  place,  the  ankle  remaining  rigid, 
weak,  and  useless  for  a  long  time. 

Compound  Fracture  into  the  Ankle-joint  is  necessaril}’  a  serious  and 
dangerous  accident.  In  this  injuiy  the  edge  of  the  fractured  bone  cuts 
through  the  integument  b^’  apparently"  a  clean  and  simple  wound,  but 
the  subjacent  areolar  tissue  is  widely^  torn,  and  extensive  inflammation 
and  suppuration  are  apt  to  set  in.  The  deep-seated  mischief  is  far  more 
extensive  than  that  which  the  Surgeon  would  be  led  to  expect  from  the 
small  and  clean-cut  wound.  Nevertheless,  the  injury-,  even  though 
severe,  may  often  be  recovered  from  with  a  good  and  useful  limb,  when 
occurring  to  young  subjects  of  sound  constitution.  As  age  advances, 
however,  and  the  constitution  becomes  broken,  less  is  to  be  expected 
fr^m  conservative  surgery. 

In  the  Treatment^  the  course  to  be  pursued  will  depend  upon  the  ex¬ 
tent  of  the  injury-.  If  the  fracture  be  not  comminuted,  the  w’ound  in 
the  soft  parts  clean  cut  and  but  moderate  in  extent,  and  the  large  ves¬ 
sels  of  the  foot  uninjured,  an  attempt  should  be  made  to  save  the  limb. 
If,  on  the  other  hand,  there  be  great  comminution  of  bone,  with  disloca¬ 
tion  of  the  foot,  and  perhaps  rupture  of  the  posterior  tibial  artery,  in  a 
person  at  or  above  the  middle  period  of  life,  amputation  should  be  prac¬ 
tised.  But  in  a  y-ounger  subject,  such  a  serious  injuiy  even  as  this  may¬ 
be  recovered  from,  if  the  Surgeon  remove  loose  fragments,  saw  off*  the 
splintered  ends  of  the  bone,  and  bring  the  soft  parts  together. 

If  an  attempt  be  made  to  save  the  limb,  whether  any-  bone  have  been 
excised  or  not,  it  should  be  placed  securely  in  a  MTntyre’s  splint  (Fig. 
159),  and  kept  immovably- fixed ;  perfect  fixity- of  the  limb  is  here  of 
the  first  consequence.  If  much  of  the  fibula  should  require  removal, 
Stromey-er  has  recommended  that  the  limb  be  amputated  instead,  lest 
an  useless  foot,  aff*ected  with  a  kind  of  valgus,  be  left.  But,  in  children, 
and  y-oung  subjects,  this  inconvenience  and  deformity  may  be  over¬ 
come  by-  mechanical  means;  and  the  probability  of  its  occurrence  would 
not,  in  my-  opinion,  justify  amputation. 


888 


SPECIAL  FKACTUKES. 


Fractures  of  the  Bones  of  the  Foot  almost  invariably  result 
,from  direct  violence,  and  are  usually  accompanied  by  bruising  and 
injury  of  the  soft  parts;  hence  much  displacement  is  rare,  and  when  the 
fracture  is  simple,  rest  and  position  alone  are  necessary.  Compound 
fractures  of  the  tarsal  or  metatarsal  bones  attended  by  much  bruising 
and  laceration,  usually  require  partial  removal  of  the  foot,  its  disarticu¬ 
lation  at  the  ankle-joint,  or  amputation  in  the  lower  third  of  the  leg, 
according  to  the  extent  and  severity  of  the  injury. 

The  only  special  fractures  of  the  foot  requiring  particular  attention, 
are  those  of  the  calcaneum  and  astragalus. 

The  Calcaneum  may  be  broken  by  direct  violence,  as  when  a  person 
jumping  from  a  height  alights  forcibly  on  his  heel,  and  thus  fractures 
the  bone.  In  this  way  the  bone  is  usually  simply  broken  across  in  front 
of  the  ligaments  without  displacement.  I  have,  however,  seen  both 
calcanea  extensively  comminuted,  being  shattered  to  pieces,  in  the  case 
of  a  lady,  who,  falling  from  a  window  on  the  third  story,  alighted  on 
her  heels.  In  some  rare  cases,  by  the  powerful  contraction  of  the 
strong  muscles  of  the  calf,  the  posterior  part  of  the  os  calcis  is  torn 
away  from  the  rest  of  the  bone. 

Sigyis. — When  the  os  calcis  is  simply  broken  through  at  its  posterior 
part  behind  the  insertion  of  the  lateral  ligaments,  the  detached  fragment 
will  be  drawn  up  by  the  action  of  the  strong  muscles  of  the  calf.  But 
when  the  fracture  occurs  across  the  body  of  the  bone,  no  displacement 
can  take  place,  owing  to  the  lateral  and  interosseous  ligaments  keeping 
the  posterier  fragments  in  position,  and  preventing  its  being  drawn 
away. 

In  the  first  form  of  fracture,  the  pain,  swelling,  flattening  of  the  heel, 
and  prominence  of  the  malleoli,  indicate  the  nature  of  the  injuiy,  even 
though  crepitus  be  wanting.  In  the  second  variety,  the  mobility  of  the 
fragment,  and  its  projection  posteriorly  by  the  action  of  the  muscles  of 
the  calf,  point  to  the  existence  of  the  fracture,  which  is  confirmed  by 
the  occurrence  of  crepitus. 

In  the  Treatment  of  these  injuries,  subduing  inflammatory  action, 
keeping  the  part  fixed  by  means  of  bandage  and  gutta-percha  splints, 
with  due  attention  to  the  relaxation  of  the  muscles,  is  all  that  (^n 
be  done.  Union  probably  occurs  by  bone  in  some  cases,  though  very 
commonly  by  fibrous  tissue. 

The  Astragalus  alone  is  rarely  broken.  Ten  recorded  cases  of  this 
injury  have  been  collected  by  Monahan :  in  nine  of  these  the  fracture 
occurred  from  falls  from  a  height  on  the  foot ;  in  one  only  from  direct 
violence.  I  have  seen  two  cases  of  fracture  of  the  astragalus  without 
implication  of  any  other  of  the  tarsal  bones.  In  one  case  it  was  the  result 
of  direct  violence ;  a  cart-wheel  passing  over  the  foot  occasioned  a  frac¬ 
ture  of  the  astragalus  through  its  neck.  There  was  no  material  displace¬ 
ment,  but  the  line  of  fracture  could  be  readily  felt,  and  crepitus  was  very 
distinctly  elicited  on  flexing  and  extending  the  foot.  No  better  treatment 
can  be  adopted  in  such  a  case  than  the  starched  bandage. 

In  the  other  case  the  fracture  was  the  result  of  indirect  violence,  the 
patient,  a  man  about  30  3^ears  of  age,  falling  from  a  height  of  about  eight 
yards,  and  alighting  on  his  feet.  In  this  case  the  fracture  was  evidently 
occasioned  by  the  foot  being  forcibly  driven  up  into  the  malleolar  arch, 
so  that  the  astragalus  was  broken  across  transversely  just  in  front  of  the 
surface  that  articulates  with  the  tibia — the  line  of  fracture  running 
obliquel}^  downwards  and  backwards,  so  that  the  whole  of  the  upper  and 
posterior  part  of  the  bone  was  detached.  This  large  fragment  was  widely 


FRACTURES  OF  THE  TARSAL  BONES. 


389 


y 

displaced,  being  drawn  outwards  and  backwards,  so  as  to  lie  between 
the  fibula  and  the  tendo  Achillis,  lacerating  the  skin  to  the  extent  of 
about  one  inch  longitudinally,  and  projecting  through  the  opening  thus 
made.  The  foot  presented  a  similar  degree  of  deformity,  which  is  repre¬ 
sented  in  the  annexed  figure  (Fig.  163).  The  outer  malleolus  projected 
greatly;  and  immediately  behind  this 
the  displaced  fragment  could  be  felt 
and  seen  partially  protruding  through 
the  rent  in  the  skin.  The  inner  mal¬ 
leolus  was  depressed ;  there  was  a  deep 
hollow  below  this.  The  os  calcis  was 
apparently  turned  somewhat  towards 
the  inner  side  of  the  foot.  The  sole 
was  arched,  the  skin  much  wrinkled, 
and  the  great  toe  forcibly  fiexed. 

There  was  a  deep  transverse  furrow  in 
front  of  the  ankle-joint.  On  discover¬ 
ing  the  nature  of  the  accident,  and 
seeing  the  hopelessness  of  reduction, 
or  rather  the  impossibility  of  main¬ 
taining  the  displaced  fragment  in  posi¬ 
tion,  I  cut  down  upon  it  by  enlarging 
the  opening  through  which  it  showed  itself,  and  then,  seizing  it  with 
strong  bone  forceps,  twisted  it  out,  dividing  the  ligamentous  connections. 
The  case  was  then  treated  as  one  of  compound  dislocation  of  the  ankle- 
joint.  About  a  month  after  the  accident  the  patient  died  of  pyaemia; 
and,  on  examining  the  foot,  it  was  found  that  the  anterior  portion  of  the 
astragalus  had  been  splintered  into  seven  fragments,  which  were  retained 
in  place  by  the  pressure  of  the  surrounding  parts.  No  other  bone  of  the 
tarsus  was  injured,  nor  was  the  malleolar  arch  fractured.  Of  this  splin¬ 
tering  of  the  anterior  fragment,  there  was  no  evidence  during  life  ;  nor 
was  there  any  reason  to  suspect  it,  as  there  was  neither  crepitus  nor  dis¬ 
placement.  The  extent  of  the  fracture  showed  the  immense  force  with 
which  the  astragalus  had  been  driven  into  and  against  the  malleolar  arch. 
Were  such  a  case  again  to  occur  to  me,  I  should  certainly  amputate  at 
once. 

The  only  similar  case  with  which  I  am  acquainted  is  one  recorded  by 
Morris  (U.  S.).  In  this  the  displaced  fragment  did  not  occasion  a  wound 
of  the  integument.  It  was  excised  owing  to  the  impossibility  of  reducing 
it ;  but  the  anterior  part  of  the  astragalus  which  was  left  fell  into  a  state 
of  caries,  which  spread  to  the  other  tarsal  bones,  rendering  amputation 
of  the  foot  eventually  necessary. 

The  other  tarsal  bones  are  but  very  rarely  fractured,  except  in  crushes 
or  gunshot  injuries  of  the  foot.  The  Scaphoid  I  have  once  seen  fractured 
by  a  fall.  It  was  in  the  case  of  a  man  who  fell  down  the  shaft  of  a  lift 
at  an  hotel,  about  60  feet  deep,  receiving  injuries  to  the  chest  and  spine 
that  eventuall}^  killed  him.  He  appeared  to  have  alighted,  in  the  first 
instance,  on  the  right  foot,  the  os  calcis  of  which  was  extensively  frac¬ 
tured,  and  the  scaphoid  broken  across  w'ithout  displacement,  the  astraga¬ 
lus  being  uninjured. 

In  all  cases  of  fracture  of  the  tarsal  bones,  whether  simple  or  com¬ 
pound,  with  so  much  displacement  as  to  render  reduction  difficult  and 
its  maintenance  impossible,  the  best  course  to  be  pursued  is  doubtless 
that  of  cutting  down  upon  and  removing  the  displaced  fragment.  I  know 
not  what  else  can  be  done. 


Fig.  163. 


Comminuted  Fracture  of  Astragalus.  Dis¬ 
placement  backwards. 


390 


DISLOCATIONS. 


Fracture  of  the  Metatarsal  Bones  usually  occurs  from  direct  violence, 
as  by  the  passage  of  the  wheel  of  a  cart  or  railway-carriage  over  the  foot, 
and  is  then  attended  with  so  much  laceration  and  bruising  of  the  soft 
parts  as  not  unfrequentl}^  to  render  amputation  necessary.  I  have  in 
one  instance  known  the  three  outer  metatarsal  bones  broken  by  a  person 
jumping  from  a  height.  But  most  commonly  their  elasticity  saves  them, 
and  the  ankle-joint  gives  way  in  such  an  accident.  There  is  but  little,  if 
any,  displacement  in  these  cases  ;  and  unless  the  soft  parts  be  so  damaged 
as  to  require  amputation,  the  support  of  a  starched  bandage  is  usually 
all  the  treatment  that  is  necessary. 


CHAPTER  XXII. 

DISLOCATIONS. 

By  a  Dislocation  is  meant  the  more  or  less  complete  displacement  of 
the  bony  structures  of  a  joint.  In  the  orbicular  joints,  as  the  hip  and 
shoulder,  the  osseous  structures  may  be  completely  separated  from  one 
another,  the  dislocation  then  being  Complete.  In  the  hinge-joints,  as 
the  elbow  and  knee,  the  osseous  surfaces  commonly  remain  partially  in 
contact,  though  displaced  from  their  normal  relations  to  one  another ; 
here  the  dislocation  is  Incomplete.  In  most  dislocations  the  integuments 
covering  the  displaced  bones  are  put  greatly  on  the  stretch  ;  but  in  some 
they  are  ruptured,  and  then  the  dislocation  is  Compound.  Besides  these 
varieties.  Surgeons  recognize  Spontaneous  dislocation,  in  which  the  dis¬ 
placement  does  not  occur  from  external  violence.  In  other  cases  again, 
the  dislocation  arises  from  Congenital  malformation  of  the  joint,  in  con¬ 
sequence  of  which  the  bones  cannot  remain  in  proper  apposition. 

Causes. — Dislocation  is  Predisposed  to*  by  various  conditions, 
amongst  which  the  arrangement  of  the  joint  appears  to  exercise  most 
influence;  orbicular  joints  being  more  liable  to  dislocation  than  any  of 
the  other  articulations,  whilst  in  some  of  the  synchondroses  it  never 
occurs.  Malgaigne  flnds  that,  of  491  cases  of  dislocation,  321  occurred 
in  the  shoulder,  34  in  the  hip,  33  in  the  clavicle,  26  in  the  elbow,  20  in 
the  foot,  besides  others  in  the  thumb,  wrist,  and  jaw. 

Dislocations  are  seldom  met  with  in  children,  in  whom  fractures 
through  the  line  of  junction  between  the  epiph3'sis  and  shaft  more  readily 
occur.  I  have,  however,  had  under  my  care  a  child,  just  one  year  old, 
with  dislocation  of  the  head  of  the  femur  on  the  os  pubis,  occasioned  by 
another  older  child  dragging  it  along  the  ground  by  its  leg ;  Kirby  and 
Madge  have  both  seen  dislocations  of  the  femur  on  the  dorsum  ilii  in 
children  of  three  and  three  and  a  half  vears  old  ;  and  Travers  has  seen 
the  hip  dislocated  in  a  boy  five  years  of  age.  In  old  people  the  bones 
are  so  brittle,  and  the  ligaments  so  tough,  that  violence  causes  fracture 
rather  than  dislocation.  Hence  it  is  principally  in  young  and  middle- 
aged  subjects  that  dislocations  are  met  with.  This  is  well  illustrated  by 
an  analysis  of  84  cases  of  dislocation  of  the  hip-joint,  collected  by 
Hamilton;  of  these,  15  occurred  under  15  years  of  age,  32  between  15 
and  30,  29  between  30  and  45,  and  8  between  45  and  85.  They  are  neces¬ 
sarily  far  more  common  in  men  than  women,  from  the  nature  of  their 


EFFECTS  OF  DISLOCATION. 


391 


respective  occupations.  Thus,  according  to  Hamilton,  of  115  disloca¬ 
tions  of  the  hip,  only  11  occurred  in  women. 

The  articular  ends  of  the  bones  of  the  extremities  are  kept  in  their 
proper  positions  by  the  arrangement  of  the  osseous  and  ligamentous 
structures  of  the  joints,  aided  by  the  continuous  tension  of  the  muscles. 
Considerable  external  violence  may  thus  be  applied  to  a  limb  without 
dislocating  it.  If,  however,  the  muscles  be  taken  by  surprise,  or  if  they 
have  been  weakened  by  previous  injury  of  any  kind,  the  joint  becomes 
predisposed  to  dislocation,  and  may  be  displaced  under  the  influence 
of  very  slight  causes ;  especially  if  it  be  one  where  the  articulating 
surface  is  shallow  and  the  ligaments  are  comparatively  weak.  In  this 
way  the  same  joint  may  be  repeatedly  dislocated.  Thus  I  have  seen  a 
man  whose  humerus  had  been  dislocated  between  forty  and  fifty  times, 
owing  to  a  weakened  state  of  the  deltoid. 

The  Direct  Causes  of  dislocation  are  external  violence  and  muscular 
action.  External  violence  may  act  directlj'  upon  a  joint,  forcing  or 
twisting  the  articular  ends  asunder,  as  happens  when  the  foot  is  dis¬ 
placed  by  a  twist  of  the  ankle,  or  when  the  thumb  is  dislocated  backwards 
by  a  blow.  But  more  commonly  the  force  acts  at  a  distance  from  the 
joint  that  is  displaced,  and  the  head  of  the  bone  is  thrown  out  of  its 
socket  by  the  “  lever-like  movement  of  the  shaft,”  as  happens  when  the 
head  of  the  humerus  is  dislocated  by  a  fall  on  the  hand,  or  when  the 
head  of  the  femur  is  dislocated. 

Muscular  action  alone  may  cause  the  dislocation  of  a  bone,  even 
though  the  part  be  previously  in  a  sound  state.  Thus,  the  lower  jaw 
has  been  dislocated  by  excessive  gaping,  and  the  humerus  by  making  a 
violent  muscular  effort.  If  the  joint  have  already  been  weakened  by 
previous  injury  or  disease,  muscular  action  is  especially  apt  to  occasion 
its  displacement.  Congenital  dislocations,  in  all  probability,  arise  from 
irregular  muscular  contractions  in  the  foetus,  by  which  the  bones  are 
displaced,  and  the  normal  development  of  the  joint  is  interfered  with. 
In  dislocations  of  the  orbicular  joints,  after  the  head  of  the  bone  has 
been  thrown  out  of  its  articular  cavit}’,  it  is  often  still  further  displaced 
by  the  contraction  of  the  muscles,  which  continues  until  they  have 
shortened  themselves  to  their  full  extent,  or  until  the  dislocated  bone 
comes  into  contact  with  some  osseous  prominence  that  prevents  its 
further  retraction. 

Signs. — The  existence  of  a  dislocation  is  rendered  evident  by  the 
change  in  the  shape  of  the  joint,  and  in  the  relation  of  the  osseous 
prominences  to  one  another :  by  the  articular  end  of  the  displaced  bone 
being  felt  in  a  new  position ;  and  by  an  alteration  in  the  length  of  the 
limb,  and  in  the  direction  of  its  axis.  Besides  this,  there  are  after  a 
time,  if  not  immediately  on  the  occurrence  of  the  accident,  impaired 
motion  of  the  injured  articulation,  and  pain  in  and  around  it. 

Effects. — The  effects  of  dislocation  on  the  structure  of  a  joint  are 
always  serious.  The  bones  are  not  unfrequently  fractured  as  well  as 
displaced,  more  particularly  in  hinge-joints ;  the  cartilages  may  be  in¬ 
jured  ;  and  the  ligaments  are  always  much  stretched  and  more  or  less 
torn,  the  capsule  of  the  joint  suffering  especially.  This  is  always  torn 
by  the  pressure  of  the  head  of  the  bone  in  dislocation  of  orbicular  joints: 
in  those  of  hinge-joints,  it  may  escape.  The  situation  of  the  slit  in  the 
capsule  is  of  great  importance  in  reference  to  reduction.  It  commonly 
occurs  in  the  shoulder  towards  the  attachment  around  the  glenoid 
cavity ;  in  the  hip,  as  Busch  has  pointed  out,  at  the  acetabular  margin. 
In  many  cases,  the  muscles  and  tendons  in  the  immediate  neighborhood 


892 


DISLOCATIONS. 


are  lacerated  as  well  as  displaced,  and  the  vessels  and  nerves  compressed. 
The  skin  is  commonly  stretched,  and  sometimes  ruptured,  when  the 
dislocation  becomes  compound.  If  the  dislocation  he  simple,  and  if 
reduction  be  speedily  effected,  these  injuries  are  soon  repaired ;  and 
although  a  good  deal  of  stiffness  may  continue,  the  functions  of  the 
joint  are,  in  general,  not  permanentl}^  interfered  with. 

If  the  dislocation  be  left  unreduced,  important  changes  take  place 
within  and  around  the  joint,  in  the  bony  structures,  the  ligaments, 
capsule,  and  muscles.  The  changes  in  the  bony  structures  are  very 
slow,  differing  in  this  respect  materially  in  ordinary  traumatic  disloca¬ 
tions,  from  what  takes  place  in  a  joint  that  has  been  dislocated  as  the 
result  of  disease.  If  the  articulation  be  an  orbicular  one,  as  the  shoulder 
or  hip,  the  cavity,  whether  glenoid  or  acetabular,  undergoes  very  gradual 
changes  in  outline  and  depth  ;  its  circumference  becomes  contracted,  less 
regular,  more  angular,  and  it  eventually  shallows.  These  changes  are  so 
slow  in  the  adult,  that  several  3"ears  will  elapse  before  they  have  gone  on 
to  such  a  degree  as  to  prevent  the  displaced  head  of  the  bone  from  being 
put  back.  In  children  and  young  people  they  are  more  rapid  and  com¬ 
plete,  and  the  cavity  fills  up  with  a  dense  fibrous  deposit.  In  the  hinge- 
joints,  the  articular  ends  of  the  displaced  bones  become  altered  in  shape — 
flattened  or  angular,  with  the  osseous  projections  less  strongly  marked. 
The  incrusting  cartilage  is  graduall}’-  absorbed,  and  the  bone  smoothed. 
The  ligaments  are  shortened  and  wasted;  and  a  false  joint  forms  around 
the  articular  end  of  the  bone  in  its  new  situation.  In  some  cases,  the 
bone  upon  which  the  dislocated  head  rests  becomes  depressed  into  a 
shallow  cup-shaped  cavity,  so  as  to  receive  it ;  in  others,  the  depression 
is  formed  by  the  elevation  of  a  rim  of  callus  upon  the  subjacent  bone ; 
and  in  both  instances  the  areolar  tissue  in  the  neighborhood  becomes 
consolidated  into  a  fibroid  capsule  surrounding  and  fixing  the  bone  in 
its  new  situation,  and  usually  admitting  of  but  a  limited  degree  of 
motion.  The  soft  structures  that  have  been  lacerated  at  the  time  of  the 
dislocation  become  matted  together  by  plastic  material ;  the  muscles 
shorten,  atroph}",  and  at  last  undergo  fatty  degeneration  from  disuse: 
the  neighboring  vessels  and  nerves  may  become  attached  to  the  new 
joint,  or  their  sheaths  become  incorporated  with  the  altered  structures 
in  contact  with  them. 

Treatment. — In  the  treatment  of  dislocations,  the  first  and  principal 
indication  consists  in  replacing  the  bone  in  its  normal  situation  as  speedily 
as  possible.  In  doing  this,  the  Surgeon  has  two  great  difficulties  to  over¬ 
come  :  1,  the  contraction  of  the  muscles  of  the  part ;  and  2,  the  resistance 
arising  from  the  anatomical  structure  of  the  joint  and  the  laceration  of 
the  capsule. 

1.  One  great  obstacle  to  reduction  in  most  dislocations  is  the  tonic 
contraction  of  the  muscles  inserted  into  or  below  the  displaced  bones ; 
and  in  the  reduction  of  the  dislocation  the  Surgeon’s  efforts  are  chiefly 
directed  to  overcome  this  contraction.  The  amount  of  resistance  due 
to  muscular  contraction  may  be  measured  by  the  efforts  produced  by 
anaesthetizing  the  patient.  So  much  of  the  resistance  as  is  overcome 
b}^  putting  the  patient  under  the  influence  of  ether  or  chloroform,  is  due 
to  muscular  contraction.  All  that  which  continues  after  this,  is  due  to 
purel}"  mechanical  causes  connected  with  the  arrangement  of,  or  injury 
inflicted  upon,  the  osseous  and  ligamentous  structure  of  the  joint.  The 
resistance  offered  b^'  the  muscles  is  of  several  different  kinds,  and  is  de¬ 
pendent  on  different  causes.  The  influence  exercised  by  the  patient’s  will, 
and  the  tonic  contraction  or  passive  force  exerted  bj^  the  shortened  and 


TREATMENT  OF  DISLOCATION. 


893 


displaced  muscles,  undoubtedly  often  offer  great  obstacles  to  reduction. 
But  more  serious  than  these  by  far  is  the  reflex  or  spasmodic  action, 
which  the  patfent  is  incapable  of  controlling,  and  which  can  only  be 
overcome  by  force,  by  faintness,  or  by  the  paral3^zing  influence  of  anaes¬ 
thetics.  The  longer  the  dislocation  is  left  unreduced,  the  more  powerful 
does  this  become ;  being  less  at  the  moment  of  the  accident  and  immedi¬ 
ately  afterwards,  than  at  any  subsequent  period.  Hence  reduction  should 
be  attempted  as  soon  as  possible  after  the  occurrence  of  the  accident ; 
and,  if  the  patient  be  seen  at  once,  the  bone  may  sometimes  be  replaced 
without  much  difficulty  by  the  unaided  efforts  of  the  Surgeon.  Thus 
Liston  reduced  a  dislocated  hip  by  his  own  endeavors  immediately 
after  the  accident  occurred.  If  a  few  hours  have  elapsed,  the  muscular 
tonicitj’  becomes  so  great  that  special  means  must  be  adopted  in  order 
to  diminish  it ;  and  if  some  weeks  or  months  have  been  allowed  to  pass 
by,  the  dislocation  may  have  become  irreducible,  partly  owing  to  perma¬ 
nent  contraction  of  the  muscles  which  have  been  shortened  by  the 
approximation  of  their  attachments,  which  contraction  it  is  impossible 
to  overcome,  but  chiefly  to  the  cohesion  of  the  surrounding  tissues,  and 
the  formation  of  adhesions  about  the  head  of  the  bone.  The  muscular 
resistance  is  greatest  when  an  attempt  is  made  at  reduction  by  forcible 
traction  in  the  direction  of  the  longitudinal  axis  of  the  limb. 

In  the  reduction  of  a  recent  dislocation,  advantage  ma}”  sometimes  be 
taken  of  the  occurrence  of  faintness,  or  of  the  patient’s  attention  being 
distracted  to  other  matters,  in  order  to  effect  the  return,  the  muscles 
being  then  taken  b^^  surprise,  and  the  bone  readily  slipping  into  its 
place.  Such  aids  as  these,  however,  cannot  be  depended  upon  ;  and 
muscular  relaxation  should  be  induced  by  the  administration  of  chloro¬ 
form  or  ether.  By  the  employment  of  these  valuable  agents,  the  mus¬ 
cles  of  the  strongest  man  ma^'  be  rendered  so  perfectly  flaccid  and 
powerless  in  a  few  minutes  as  to  oppose  no  action  whatever  to  reduction, 
which  has  thus  been  wonderfull}’’  simplified  and  facilitated.  In  no 
department,  indeed,  of  practical  surgery  has  the  administration  of  anaes¬ 
thetic  agents  been  attended  by  more  advantageous  results  than  in  this. 

Mechanical  contrivances  are  much  less  frequentl3’’  used  for  the  reduc¬ 
tion  of  dislocation,  since  the  emplo3^ment  of  anaesthetics,  than  formerly. 
It  is,  however,  occasionally  necessary  to  employ  apparatus  calculated  to 
fix  the  articular  surface  from  which  the  bone  has  escaped,  and  to  draw 
down  or  disentangle  the  displaced  bone  to  such  an  extent  that  it  may 
be  replaced  on  the  surface  on  which  it  should  be  lodged.  If  the 
patient  has  not  been  anaesthetized,  it  will  be  found  that,  when  the  bone 
is  well  brought  down  b3’'  the  extending  force  so  as  to  be  opposite  its 
articulation,  being  disentangled  from  osseous  points  upon  which  it  may 
have  hitched,  or  from  the  edge  of  the  slit  in  the  lacerated  capsule,  it  will 
be  drawn  at  once  into  its  proper  position  by  the  action  of  its  own  mus¬ 
cles,  with  a  sudden  and  distinct  snap  ;  the  muscles  of  the  part  being  the 
most  efiicient  agents  in  the  reduction,  so  soon  as  the  bone  is  placed  in  a 
position  for  them  to  act  upon  it.  When,  however,  the  patient  has  been 
placed  under  the  influence  of  chloroform,  the  muscular  system  being 
thoroughly  relaxed,  the  bone  will  not  slip  into  its  place  with  a  snap  or 
sudden  jerk,  but  is  reduced  more  quietl3^,  and  rather  b3’  the  efforts  of  the 
Surgeon  than  by  any  sudden  contraction  of  its  own  muscles.  It  is 
important  to  note  these  differences  in  the  mode  of  reduction ;  lest  the 
Surgeon,  when  chloroform  has  been  fully  administered,  failing  to  hear 
the  snap  or  feel  the  jerk  which  he  expected,  should  imagine  the  bone  not 
to  be  reduced,  and  continue  to  use  an  improper  degree  of  extension. 


394 


DISLOCATIONS. 


Manipulation  of  the  limb — that  is,  impressing  certain  movements  upon 
it  of  extension  and  flexion,  of  adduction  and  of  abduction — is  often  of 
essential  service  in  effecting  reductions.  It  is  useful  in  those  cases,  par- 
ticularlj",  where  the  obstacle  to  replacement  of  the  head  of  the  bone  is 
due  less  to  muscular  contraction  than  to  the  locking  together  of  osseous 
surfaces,  or  the  impediment  offered  by  the  displacement  of  the  ligaments 
of  the  part.  In  the  hip,  elbow,  and  knee  it  has  been  especially  service¬ 
able,  and  has  now  taken  the  place  of  many  of  the  more  formal  methods 
of  reduction  b}''  extension  in  the  axis  of  the  limb,  with  the  view  of  over¬ 
coming  forcible  resistance  offered  by  muscular  contractions  or  capsular 
entanglement. 

The  purely  mechanical  means  for  the  reduction  of  dislocation  are  suf¬ 
ficiently  simple  ;  the  patient’s  body,  and  the  articular  cavity  into  which 
the  luxated  bone  is  to  be  replaced,  are  fixed  by  a  split  sheet,  a  jack-towel, 
a  padded  belt,  or  some  such  contrivance,  by  which  counter-extension  is 
practised.  In  some  cases  the  hands  of  an  assistant,  or  of  the  Surgeon 
himself,  or  the  pressure  of  his  knee  or  heel,  constitute  the  best  counter¬ 
extending  means. 

Extension  may  be  made  either  by  the  Surgeon  grasping  the  limb  to  be 
reduced  and  drawing  it  downwards,  or  else  by  means  of  a  bandage  or 
jack-towel  fixed  upon  the  part,  with  the  clove-hitch  knot  applied  in  the 

way  represented  in  the  annexed  cut  (Fig.  164). 
If  more  force  be  required,  the  multipljdng 
pulleys  (Fig.  181),  or  Bloxam’s  dislocation 
tourniquet  (Fig.  191),  may  be  used,  by  which 
any  amount  of  extending  force  that  may  be 
required  can  readily  be  set  up  and  maintained. 
Jarvis’s  “adjuster”  is  an  useful  and  powerful 
instrument  for  the  same  purpose.  These  con¬ 
trivances,  however,  are  much  less  frequently 
required  now  than  formerly,  owing  to  Surgeons 
taking  advantage  of  the  paralyzing  effects  of 
chloroform  upon  the  muscular  system,  and 
consequently  not  requiring  so  much  force  to 
overcome  its  contraction,  and  emplojdng  the 
gentler  method  of  manipulation^  by  which 
resistance  is  eluded  by  attention  to  ordinar}^ 
mechanical  principles,  rather  than  overcome 
by  force.  When  any  powerful  extending  force 
is  applied,  the  skin  of  the  part  should  always 
be  protected  from  being  chafed  by  a  few  turns 
of  a  wet  roller.  The  extension  must  be  made 
slowly  and  gradually  without  any  jerking,  so 
as  to  secure  equalit}’^  of  motion  as  well  as  of 
force.  In  this  w^ay  the  contraction  of  the 
muscles  is  gradually  overcome,  whereas  sud¬ 
den  and  forcible  extension  might  excite  them 
to  reaction.  The  traction  is  most  advantageously  made  in  the  newly 
acquired  axis  of  the  limb,  without  reference  to  its  normal  direction  or  to 
the  situation  of  the  joint.  The  head  of  the  bone  is  thus  made  to  pass 
along  the  same  track  which  it  has  torn  for  itself  in  being  dislocated,  and 
thus  is  replaced  without  the  infliction  of  any  additional  violence  on  the 
surrounding  tissues. 

The  question  whether  the  extending  force  should  be  applied  to  the 
bone  that  is  actually  displaced,  or  to  the  further  end  of  the  limb,  has 


Fig.  164. 


Bandage  applied  for  Extension: 
Clove-hitch  Knot. 


TREATMENT  OF  DISLOCATION. 


395 


been  much  discussed,  and  appears  to  have  received  more  attention  than 
it  deserves.  It  is  true  that,  applying  the  extending  force  to  the 
displaced  bone  itself,  the  Surgeon  has  greater  command  over  its  move¬ 
ments,  with  less  chance  of  injury  to  the  intervening  bones  ;  whilst,  by 
applying  the  extending  force  to  the  lower  part  of  the  extremity,  he  has 
the  advantage  of  a  longer  lever  for  the  reduction  of  the  head  of  the 
bone.  This  lever,  however,  it  must  be  remembered,  is  in  man}*  cases  a 
broken  one  ;  and  it  cannot  be  made  to  act  if  the  bone  have  to  be  replaced 
in  the  direction  of  the  flexion  of  the  joints  that  exist  in  its  course.  For 
this  reason,  we  And  that  some  dislocations  are  best  reduced  by  applying 
traction  to  the  bone  itself  that  is  displaced,  as  in  luxations  of  the  femur 
and  of  the  bones  of  the  forearm ;  whilst,  in  other  cases,  as  in  the  dislo¬ 
cations  of  the  humerus,  most  advantage  is  gained  by  appljdng  the  ex¬ 
tending  force  to  the  end  of  the  limb.  But  I  look  upon  these  points  as 
of  comparatively  little  consequence  ;  believing  that,  when  the  patient  is 
not  anaesthetized,  the  muscles  of  the  limb  themselves  effect  the  reduction, 
without  the  necessit}’’  of  the  Surgeon  employing  an}’-  very  powerful 
lever-like  action  of  the  bone ;  and  that,  when  the  patient  is  paralyzed  by 
chloroform,  the  bone  is  in  most  cases  readily  replaced  by  the  simple 
movements  impressed  directly  upon  it,  or  even  upon  its  articular  end,  by 
the  hands  of  the  Surgeon. 

The  force  required  in  effecting  the  reduction  of  recent  dislocations 
is  often  very  considerable.  So  great  is  the  resistance  offered,  that  in 
some  cases  the  dislocated  bone  has  given  way  under  the  traction.  I  am 
acquainted  with  cases  in  which  the  humerus  and  the  neck  of  the  femur 
have  both  been  broken  in  effecting  the  reduction  of  recent  dislocations. 
This  accident  does  not  always  appear  to  have  been  the  result  of  any  im¬ 
proper  or  unskilful  employment  of  force,  but  in  some  cases  to  have 
occurred  from  natural  weakness  of  bone.  We  know  that  “  spontaneous” 
fractures  frequently  take  place  from  muscular  action,  often  of  a  very 
slight  kind :  and  we  can  easily  understand  that,  if  a  bone  that  would  be 
liable  to  such  ready  fracture  happened  to  be  dislocated,  it  would  almost 
of  necessity  give  way  under  the  influence  of  the  extending  or  lever-like 
force  required  to  replace  it. 

2.  The  reduction  of  dislocations  is  also  impeded  by  the  mechanical 
resistance  arising  from  the  anatomical  structure  of  the  joint  and  its  liga¬ 
ments.  In  reducing  a  dislocation,  it  is  of  especial  importance  to  attend  to 
the  relation  of  the  osseous  points  in  the  neighborhood  of  the  joint,  and  to 
disentangle  the  displaced  bone  from  any  of  these  upon  which  it  may  be 
lodged.  This  is  especiall^^  the  case  in  such  hinge-joints  as  the  jaw  and 
elbow,  in  which  the  arrangement  of  the  articulation  is  somewhat  compli¬ 
cated;  and  in  some  orbicular  joints,  as  the  hip,  where  the  reduction  is 
prevented  by  the  displacement  and  tension  of  torn  ligamentary  struc¬ 
tures.  When  the  patient  is  anaesthetized,  and  all  muscular  resistance 
has  thus  been  removed,  any  remaining  difficulty  in  effecting  reduction 
must  be  due  to  purely  mechanical  causes  dependent  on  the  disarrange¬ 
ment  of  the  bones  and  ligaments.  Under  the  older  methods  of  treatment, 
where  much  force  was  emplo^^’ed  by  pulleys  or  other  similar  contrivances, 
these  were  often  torn  through.  But,  since  the  introduction  of  manipu¬ 
lation.,  the  Surgeon  eflfects  the  reduction  by  a  far  less  degree  of  force, 
replacing  the  bone  on  simple  mechanical  principles,  by  relaxing  the  liga¬ 
ments  and  disentangling  the  bones  from  one  another.  The  situation  and 
extent  of  the  laceration  of  the  capsule  of  the  joint  is  also  of  great  impor¬ 
tance  as  offering  an  obstacle  to  reduction,  in  some  cases  constricting  the 
neck  of  the  bone,  in  others  having  one  lip  of  the  slit  in  it  pressing  against 


896 


DISLOCATIONS. 


the  bone  in  such  a  way  as  to  prevent  all  efforts  at  moving  it.  An  ex¬ 
treme  degree  of  force  is  required  to  tear  through  and  thus  overcome 
obstructions  of  this  kind  ;  but  they  may  readil}^  be  relaxed  and  slipped 
aside  by  skilful  manipulation  and  attention  to  the  position  of  the  limb. 

After  the  dislocation  has  been  reduced,  the  bone  must  be  retained  in 
position  by  proper  splints  and  bandages ;  the  joint  being  kept  quiet  for 
two  or  three  weeks,  according  to  its  size,  so  as  to  allow  proper  union  to 
take  place  in  the  capsule  and  neighboring  structures.  An}’-  consecutive 
inflammation  ma}"  often  be  prevented  by  the  continuous  application  of 
cold ;  and,  if  set  up,  must  be  treated  by  local  anti-inflammatory  means. 
After  reduction,  the  limb  must  be  kept  flrmly  fixed  and  at  rest  for  two 
or  three  weeks,  so  as  to  allow  the  lacerated  ligaments  and  capsule  to 
recover  themselves.  But  fixity  of  the  joint  must  not  be  maintained  for 
too  long  a  time,  lest  adhesions  ^orm,  often  of  a  painful  character.  These 
ma}'"  be  avoided  by  passive  motion.  If  they  have  formed,  they  may  readily 
be  broken  down  by  the  manipulations  commonly  emplo3’ed  in  such  cases 
b3"  “  bone-setters,”  who,  fixing  the  joint  b}"  pressure  of  the  thumb  on  the 
painful  spot,  in  a  manner  well  described  bj"  W.  Hood,  impart  sudden  and 
forcible  movement  to  the  limb,  b}"  which  adventitious  bands  are  ruptured. 

Dislocations  of  Old  Standing, — If  a  dislocation  have  been  left 
unreduced  for  some  weeks  or  months,  changes,  which  have  already  been 
described,  take  place  in  and  around  the  displaced  articular  structures, 
the  double  effect  of  which  is  to  render  the  replacement  of  the  bones  in 
their  normal  position  more  and  more  difficult  as  time  goes  on,  and  to  lead 
to  the  formation  of  a  new  though  imperfect  articulation  at  the  seat  of 
displacement. 

When  a  dislocation  has  been  left  permanently  unreduced  for  a  con¬ 
siderable  length  of  time,  as  for  years,  the  amount  of  utility  in  the  limb 
will  depend  parti}"  on  the  kind  of  joint  that  has  been  dislocated,  partly 
on  the  particular  variety  of  dislocation  that  has  occurred.  Thus,  as  a 
general  rule,  greater  freedom  of  movement  and  greater  utility  of  limb 
will  be  found  in  old  standing  dislocations  of  ball  and  socket  than  of  hinge- 
joints.  But  in  ball  and  socket  joints  some  dislocations  will,  if  left  unre¬ 
duced,  be  attended  with  less  evil  consequences  to  the  i^atient  than  others. 
Thus,  in  the  subglenoid  dislocation  of  the  shoulder  and  the  sciatic  of  the 
hip,  the  limb  will  recover  itself  to  a  greater  extent  than  in  the  other  forms 
of  the  same- kind  of  injury  affecting  these  joints. 

Treatment. — In  cases  of  very  old  and  irremediable  unreduced  disloca¬ 
tion,  much  may  be  done  by  means  of  regularly  conducted  passive  move¬ 
ments  to  increase  the  mobility  of  the  part,  and  by  means  of  friction  and 
warm  douches  to  relieve  the  tension  and  painful  stiffness.  In  cases  not 
so  old,  but  in  which  some  time  has  elapsed  since  the  occurrence  of  the 
dislocation,  two  questions  always  present  themselves  to  the  Surgeon: 
1.  Is  it  possible  to  replace  the  dislocated  bone?  2.  Is  it  desirable  or 
prudent  to  attempt  reduction  ? 

The  possibility  of  reducing  the  dislocation  will  depend  partly  upon  the 
joint  that  is  dislocated  arid  the  nature  and  extent  of  the  dislocation,  but 
chiefly  on  the  length  of  time  during  which  the  bone  has  been  out  of 
place.  Dislocations  of  the  orbicular  joints  generally  can  be  reduced  at 
a  much  later  period  than  those  of  the  ginglymoid  ;  those  of  the  shoulder 
can  be  reduced  after  a  longer  lapse  of  time  than  those  of  the  hip.  The 
subglenoid  dislocation  of  the  shoulder  and  that  of  the  hip  on  the  dorsum 
ilii  are  susceptible  of  reduction  at  a  later  period  than  the  other  luxations 
of  the  same  joints. 

The  latest  period  at  which  reduction  is  possible  has  been  variously 


OLD  UNREDUCED  DISLOCATIONS. 


897 


estimated  by  different  Surgeons.  Sir  A.  Cooper  gives  three  months  for 
the  shoulder  and  eight  weeks  for  the  hip.  As  a  general  statement,  this 
was  no  doubt  a  tolerably  correct  one  at  the  time  when  it  was  made, 
although  reduction  has  been  effected  at  later  periods  than  those  given 
by  Cooper.  Thus  Breschet  reduced  a  dislocation  of  the  hip  at  the  78th 
day,  and  Travers  at  the  fifth  month.  But  we  maj^  now  go  far  be3’ond 
this  as  the  limit  of  possible  reduction.  Brodhurst  has  reduced  the 
shoulder  on  the  175th  day;  Smith  (U.’S.)  in  one  case  at  the  seventh 
month,  in  another  at  ten  months  and  a  half;  Blackman,  of  Cincinnati,  a 
dislocation  of  the  femur  on  the  dorsum  ilii  at  six  months ;  Dupierris,  of 
the  Havana,  one  at  over  six  months,  in  a  bo}",  and  this  without  chloro¬ 
form  ;  and  A.  W.  Smith,  after  nine  months  had  elapsed. 

The  Obstacles  to  the  Reduction  of  old-standing  dislocations  are  rather 
pathological,  than  ph3^siological  and  anatomical  as  in  the  case  of  recent 
displacements.  The^^  are  of  several  distinct  kinds:  1.  The  powerful 
tonic  contraction  of  the  shortened  and  displaced  capsular  muscles ;  2. 
The  organic  changes  that  have  taken  place  in  these  muscles,  arising 
partly  from  their  cicatrization  after  laceration,  parti}'  from  a  kind  of 
rigid  atroph}',  the  consequence  of  infiammatory  action  and  of  disease ; 
3.  Adhesions  that  form  between  the  lacerated  capsule  and  muscles  and 
the  displaced  head  of  the  bone  ;  4.  Lastly,  as  a  more  remote  consequence, 
pathological  changes  in  the  articulating  surfaces  themselves,  b}'  which 
their  shape  becomes  altered  and  the  socket  shallowed,  contracted,  and 
perhaps  ultimately  obliterated  b}’’  fibroid  deposits. 

In  order  to  overcome  these  obstacles  a  considerable  amount  of  force 
must  be  used,  as  adhesions  and  contractions  have  to  be  stretched  and 
torn  asunder.  This  is  effected  b}'  the  multipl3'ing  pulle3'S  and  b}^  manipu¬ 
lation  under  chloroform.  In  employing  the  necessary  force,  care  must 
be  takerr  to  protect  the  skin  from  abrasion,  or  even  laceratiorr,  b}^  the 
use  of  wet  fiannel  bandages  or  wash-leather.  The  reducing  force  exer¬ 
cised  by  the  pulle3"s  must  be  considerable  ;  but  it  should  be  accompanied 
with  free  rotatory  manipulations  and  movements  of  the  head  of  the  bone, 
so  as  to  loosen  it  from  its  adhesions  ;  and  reduction  will  usually  be 
efiected  in  this  wa}'  rather  tharr  by  forcible  traction  onl}'. 

Chloroform  is  of  inestimable  service  in  these  cases ;  and  it  is  by 
the  anaesthesia  produced  b}'  it  that  the  Surgeon  has  beerr  enabled  to  pro¬ 
long  materiall}'  the  limit  of  possible  reduction.  But,  in  the  reduction 
of  old  dislocations,  chloroform  does  not  afford  exactl}'  the  same  kind  of 
service  as  in  those  of  recent  date.  Irr  a  recent  dislocation  the  chief 
obstacle  is  muscular  contraction ;  and,  b}'  relaxing  this,  chloroform 
enables  the  Surgeon  to  replace  the  bone  at  once  without  difficult}'.  In 
old  dislocations  the  obstacles,  as  has  just  been  stated,  consist  in  various 
pathological  changes  that  have  taken  place  around  and  in  the  displaced 
bones.  These  conditions  cannot  be  influenced  by  anaesthesia  ;  and  hence, 
except  as  a  means  of  producing  insen sibilit}’’  to  pain  and  preventing 
instinctive  or  voluntary  muscular  resistance  on  the  part  of  the  patient, 
chloroform  will  not  aid  the  Surgeon. 

It  must  be  borne  in  mind  that  the  reduction  of  old  dislocations  is  not 
oiil}^  a  work  of  very  considerable  difficulty,  but  also  of  no  little  danger. 
If  several  months  have  elapsed,  the  obstacles  arising  from  the  patholo¬ 
gical  changes  already  mentioned  will  usuall}'  be  so  obstinate  as  to  render 
the  reduction  impossible  without  the  emplo3'ment  of  a  dangerous  amount 
of  force,  and  in  many  cases  they  will  prevent  the  possibility  of  reduc¬ 
tion,  whatever  force  be  employed. 

The  Accidents  liable  to  occur  during  attempts  to  reduce  old  disloca- 


398 


DISLOCATIONS. 


tions,  whether  successful  or  not,  are  the  following:  1.  Laceration  of  the 
skin  by  the  constriction  and  pressure  of  the  bands  to  which  the  puller’s 
are  attached.  2.  Laceration  of  the  muscles:  thus  the  pectoral  has  been 
torn  through  in  attempting  reduction  of  old  dislocation  of  the  shoulder. 
3.  The  development  of  inflammation  and  suppuration  around  the  dislo¬ 
cation,  by  the  violence  to  which  the  soft  parts  have  been  subjected. 
From  this  cause  death  has  several  times  resulted,  in  attempts  at  reducing 
old  hip-dislocations.  4.  ExtensWe  extravasation  of  blood  from  the 
rupture  of  small  vessels  in  the  lacerated  soft  parts,  giving  rise  to  wide¬ 
spread  ecchymosis.  5.  Laceration  of  one  of  the  larger  veins.  A  patient 
of  Froriep’s  died  from  this  cause,  after  rupture  of  the  axillary  vein,  in 
an  attempt  to  reduce  an  old  dislocation  of  the  shoulder.  6.  Laceration 
of  an  arterv,  and  the  formation  of  a  diffused  traumatic  aneurism.  This 
serious  accident  has  happened  at  least  twelve  times  in  attempted  reduc¬ 
tion  of  old  dislocations  of  the  shoulder.  The  brachial  artery  has  also 
been  torn  in  attempted  reduction  of  dislocated  elbow.  7.  Laceration  of 
neighboring  nerves.  Those  of  the  axillary  plexus  have  been  torn  in 
attempted  reduction  of  dislocation  of  the  shoulder,  and  the  median  in 
that  of  the  elbow.  8.  Fracture  of  the  dislocated  bone.  This  serious 
accident  has  usually  happened  when  the  Surgeon,  after  the  employment 
of  extension,  has  attempted  to  put  in  force  transverse  movements  of 
the  bone,  or  has  used  it  as  a  lever ;  wLen  it  has  given  way,  usually  high 
up  near  the  head,  at  other  times  in  the  shaft.  It  is  possible  that  in  some 
cases  this  may  have  been  predisposed  to  by  the  bone  having  become 
weakened  by  want  of  use.  It  has  occurred  several  times  in  the  humerus, 
and  at  least  eight  times  in  the  femur,  in  attempts  at  reducing  old  dislo¬ 
cations  of  these  bones.  In  most  of  the  recorded  cases  the  bone  has 
readily  united,  and  the  condition  of  the  patient  has  not  been  materially, 
if  at  all,  influenced  for  the  worse,  except  that  reduction  of  the  disloca¬ 
tion  has  necessarily  been  rendered  impossible.  9.  Neighboring  bones 
have  been  fractured,  such  as  the  ribs  and  the  glenoid  cavity  in  the 
endeavor  to  reduce  dislocation  of  the  shoulder,  and  the  acetabulum  in 
attempted  reduction  of  a  luxated  hip.  10.  The  limb  has  actually  been 
torn  off.  This  remarkable  and  distressing  accident  happened  to  Guerin, 
of  Paris,  in  attempting  the  reduction  without  pulle3^s,  and  merely  by 
the  traction  of  assistants,  of  a  dislocation  of  the  shoulder  of  three 
months’  standing,  in  a  woman  63  3’ears  of  age,  the  limb  being  suddenly 
torn  off  at  the  elbow.  On  examination  the  bones  w^ere  found  porous, 
the  muscular  and  other  soft  structures  pulp}^,  the  limb  having  thus  evi¬ 
dently  lost  its  natural  strength  and  elasticity. 

The  occurrence  of  these  various  accidents  and  injuries,  in  the  attempted 
reduction  of  old  dislocations,  cannot  alwa3^s  with  justice  be  attributed 
to  the  employment  of  an  improper  degree  of  force  on  the  part  of  the 
Surgeon.  The  liabilit3’’  to  them  must  rather  be  looked  upon  as  a  neces- 
saiy  and  inevitable  accompaniment  of  all  attempts  at  putting  back  into 
its  place  a  bone  which  has  been  dislocated,  and  left  unreduced  for  many 
w’eeks  or  several  months.  During  this  period  it  usually  contracts  adhe¬ 
sions  of  a  very  dense  kind  to  the  parts  amongst  which  it  lies ;  and,  as 
it  cannot  be  replaced  in  its  articular  cavity  until  these  adhesions  have 
been  torn  or  broken  through,  it  is  easy  to  understand  how,  in  the 
attempt  to  do  this,  neighboring  soft  parts,  vessels,  or  nerves  may  give 
wa3",  or  the  bone  itself  may  3d  eld  to  the  force  that  must  be  applied  to  it 
in  order  to  lift  it  out  of  its  new  bed. 

The  liability  to  the  occurrence  of  these  accidents  should  make  the 
Surgeon  very  cautious  how  he  recommends  the  attempt  at  the  reduction 


COMPOUND  DISLOCATION. 


399 


of  old-standing  dislocations.  If  after  a  time  the  new  joint  have  become 
tolerably  mobile,  and  be  not  painful,  it  may  be  better  to  leave  the  bone 
unreduced,  rather  than  expose  the  patient  to  great  risk,  with  a  slender 
prospect  of  eventual  success.  If  the  unreduced  dislocation  be  stiff  and 
painful,  much  may  be  done  by  passive  motion,  frictions,  and  douches, 
to  improve  the  patient’s  condition. 

The  Subcutaneous  Section  of  muscles,  tendons,  and  bands  of  adhe¬ 
sions  in  the  neighborhood  of  the  dislocated  joint,  has  been  proposed  by 
Dieffenbach  as  a  means  of  facilitating  reduction  in  old-standing  cases; 
and  he  relates  an  instance  in  which,  by  these  means,  a  shoulder  that  had 
been  dislocated  for  two  years  was  reduced.  In  many  cases  in  which  this 
plan  has  been  tried,  the  success  has  not  been  commensurate  with  the 
expectations  raised  respecting  it ;  and  in  other  instances,  of  which  I 
have  seen  two  or  three,  the  operation  has  been  followed  by  sloughing 
and  other  serious  evils,  while  it  has  not  been  attended  by  any  benefit  in 
facilitating  reduction. 

Compound  Dislocation  is  one  of  the  most  serious  injuries  to 
which  a  limb  can  be  subjected.  Not  only  is  there  such  extensive  lacera¬ 
tion  of  the  soft  parts  that  cover  and  enter  into  the  formation  of  the  joint 
as  to  give  rise  to  the  most  severe  forms  of  traumatic  arthritis,  but  the 
bones  are  often  fractured,  and  the  main  vessels  of  the  limb  perhaps 
greatly  stretched  or  torn. 

The  Treatment  of  a  compound  dislocation  must  be  conducted  on  the 
same  principles  that  guide  the  Surgeon  in  the  management  of  a  wounded 
joint;  obtaining  union,  if  possible,  by  the  first  intention,  subduing  in¬ 
flammatory  action,  and  letting  out  matter  as  it  forms.  Owing  to  the 
rupture  of  the  ligaments  and  of  the  muscular  attachments,  there  is 
usually  no  difficulty  in  the  reduction,  the  bones  being  readily  replaced  ; 
but  the  danger  consists  in  the  destructive  inflammatory  action  that  will 
be  set  up  in  the  joint  and  limb  from  the  extensive  injury  inflicted  upon 
them.  This  varies  greatly,  according  to  the  size  and  situation  of  the 
joint,  and  the  state  of  the  soft  parts.  If  it  be  small,  as  one  of  the  pha¬ 
langeal  articulations,  the  dislocation  may  be  reduced,  and  the  parts 
covered  with  cold  lint.  If  it  be  one  of  the  larger  joints,  the  line  of 
practice  will  vary  according  to  other  circumstances  than  the  mere  dislo¬ 
cation.  Thus,  if  it  be  in  the  upper  extremity,  the  patient  being  healthy, 
and  the  soft  parts  not  very  extensively  contused  or  torn,  the  bones 
may  be  replaced,  cold  irrigation  assiduously  applied,  and  antiphlogistic 
treatment  pursued.  If  there  be  fracture  conjoined  with  the  dislocation, 
resection  should  be  practised,  as  was  successfully  done  by  Hey  in 
several  cases  of  injury  of  the  elbow  of  this  description;  but  if  the  soft 
parts  be  greatly  injured  as  well,  and  especially  if  the  bloodvessels  and 
nerves  of  the  limb  have  suffered,  amputation  must  be  performed.  In 
the  lower  extremity,  amputation  is  more  frequently  necessary;  in  the 
knee,  almost  invariably  so.  Sir  A.  Cooper  states  that  he  knows  no 
accident  that  more  imperatively  demands  amputation  than  compound 
dislocation  of  this  joint.  Yet  there  are  exceptions  to  this  rule;  thus. 
White  had  a  case  of  compound  dislocation  of  the  knee-joint  in  a  boy, 
nine  years  of  age,  at  the  Westminster  Hospital,  in  which  he  saved  the 
limb  by  sawing  off  the  condyles  of  the  femur  and  reducing  the  bone. 
In  the  compound  dislocations  of  the  ankle  and  the  astragalus,  an 
attempt  should  generally  be  made  to  save  the  limb,  in  the  way  that 
will  be  more  specially  pointed  out  when  we  come  to  treat  of  these  inju¬ 
ries. 

After  recovery  from  compound  dislocations,  the  joint  will  often  remain 


400 


DISLOCATIOXS. 


permanently  stiffened;  hence  attention  to  position  during  the  treatment 
is  essentially  required.  In  many  cases,  however,  veiy  good  motion  is 
ultimately  obtained,  though  the  stiffness  may  continue  for  some  length 
of  time. 

Complications. — Fracture  of  the  Shaft  of  one  of  the  Long  Bones 
with  Dislocation  of  its  Head  increases  considerably  the  difficulty  of 
reduction.  In  these  circumstances,  it  has  been  recommended  to  consoli¬ 
date  the  fracture  first,  and  then  to  attempt  the  reduction.  But  to  do 
this  is  only  to  defer  and  increase  the  difficulties.  At  least  seven  or 
eight  weeks  must  elapse  before  the  fracture  can  be  sufliciently  firmly 
united  to  bear  the  requisite  traction  to  reduce  so  old  a  dislocation;  and 
then  there  will  be  great  chance  of  rupture  of  the  callus,  and  certainly 
extreme  dififlculty  in  the  reduction.  It  therefore  appears  to  me  much 
safer,  under  all  circumstances,  to  reduce  the  dislocation  at  once,  and 
afterwards  to  treat  the  fracture  in  the  usual  way.  In  reducing  a  dislo¬ 
cation  complicated  with  fracture  of  the  shaft  of  the  displaced  bone,  the 
fracture  must  first  be  put  up  very  firml}"  indeed,  with  wooden  splints 
completely  encasing  the  limb.  The  patient  must  then  be  put  fully 
under  the  influence  of  chloroform,  which  is  of  the  most  essential  service 
in  these  cases  ;  and,  when  the  muscles  are  completely  relaxed,  extension 
and  counter-extension  being  made  in  the  usual  way,  the  reduction  may 
be  effected.  The  extending  means  should  always  be  applied  upon  the 
splints,  so  that  there  may  be  no  dragging  upon  the  fracture.  In  this 
way,  I  have  reduced,  without  any  difficult}^,  a  dislocation  of  the  head  of 
the  humerus  into  the  axilla,  complicated  with  comminuted  fracture  of 
the  shaft  of  the  bone,  in  a  remarkably  muscular  man  to  whom  I  was 
called  by  Byam ;  and  about  the  same  time  I  had  under  my  care  at  the 
Hospital  a  case  of  dislocated  elbow,  with  fracture  of  the  shaft  of  the 
humerus,  that  was  reduced  with  ease  in  the  same  way.  The  difficulty  in 
reduction  is  necessarily  increased  by  the  proximity  of  the  fracture  to 
the  dislocated  joint ;  and  when  the  epiphysis  is  broken  off  from  the  shaft 
and  dislocated,  the  difficulty  may  be  great,  but  is  not  insuperable. 
Some  years  since,  I  assisted  H.  Smith  and  Dunn  in  the  reduction  of  a 
dislocation  of  the  humerus  with  fracture  of  the  surgical  neck  of  the 
bone,  the  displaced  head  lying  to  the  inner  side  of  the  coracoid  process. 
In  this  case  the  patient,  a  young  man  who  had  sustained  the  injury  by 
a  fall  in  an  epileptic  fit,  was  put  under  chloroform,  and  when  he  was  fully 
anaesthetized  the  disiffaced  head  of  the  bone  was  easily  replaced  at  once; 
the  patient  recovering  with  an  excellent  and  useful  arm.  After  the  bone 
has  been  reduced,  the  fracture  should  be  treated  in  the  ordinary  way. 

When  a  Simple  Fracture  extends  into  the  Articular  End  of  the  Bone^ 
as  in  some  dislocations  about  the  elbow  and  ankle,  there  is  no  material 
increase  in  the  danger  of  the  case  or  in  the  difficulty  of  its  management. 

In  Compound  Dislocation  with  Fracture  of  the  Articular  Ends,  re¬ 
moval  of  splinters,  and  partial  resection  or  amputation,  will  be  required, 
according  to  the  seat  and  extent  of  injury. 

Spontaneous  Dislocations  may  occur  either  suddenly  or  gradually, 
according  to  the  nature  of  the  cause  that  gives  rise  to  them. 

Spontaneous  dislocation,  if  that  term  can  be  properly  applied  to  such 
cases,  is  often  met  with  on  the  hip  as  the  result  of  old  disease.  The 
ligamentous  and  cartilaginous  structures  having  become  destroyed,  the 
head  of  the  bone  atrophied  and  absorbed,  the  articular  surfaces  become 
readily  displaced  under  the  influence  of  slight  muscular  action. 

There  is,  however,  a  second  and  more  rare  form  of  spontaneous  dislo¬ 
cation  to  which  the  hip  and  shoulder  are  liable,  and  which  has  been 


CONGENITAL  DISLOCATIONS. 


401 


especially  studied  hy  Stanley.  In  this  dislocation  the  head  of  the  hone 
slips  out  of  the  articulation  without  any  veiy  marked  sign  of  disease 
about  the  joint,  and  certainly  without  any  previous  destruction  of  it. 
In  these  cases  there  is  either  a  paralytic  condition  of  the  capsular 
muscles^  as  has  been  observed  several  times  in  the  shoulder,  the  deltoid 
having  become  paralyzed  and  thus  having  allowed  the  bone  to  slip  out 
of  place ;  or,  as  has  been  noticed  in  the  hip,  obscure  rheumatic  or 
neuralgic  pains  have  for  some  time  been  seated  in  the  joint.  The 
dislocation  may  not  be  confined  to  one  joint,  but  may  afiect  several. 
Thus,  some  time  ago  there  was  a  case  in  University  College  Hospital, 
in  which  both  shoulders  and  hips  were  dislocated  simultaneously.  In 
many  cases  it  occurs  suddenly,  and  often  without  any  pain,  the  deformit}’ 
of  the  limb  attracting  attention ;  though  in  others  it  has  been  preceded 
b}"  rheumatic  affection  of  the  joint. 

There  is  a  third  variety  of  spontaneous  dislocation,  in  which,  the  joint 
having  been  dislocated  and  reduced,  the  muscular  and  ligamentous 
structures  have  become  so  weakened  that  ever  afterwards  it  slips  out 
of  place  on  tlie  application  of  slight  force,  or  at  will  on  the  patient 
throwing  the  muscles  of  the  limb  into  action. 

The  Treatment  of  these  cases  is  not  very  satisfactoiy.  Reduction  in 
many  cannot  be  accomplished;  while  in  others  it  may  be  effected  readily 
enough,  but  the  bone  cannot  be  fixed  in  the  joint,  out  of  which  it  slips 
again.  In  a  case  of  spontaneous  dislocation  of  the  hip,  without  any 
apparent  disease  of  the  joint,  occurring  in  a  young  woman,  I  readily 
effected  reduction  by  the  pulleys,  three  weeks  after  the  occurrence  of 
the  displacement.  The  limb  was  then  fixed  with  the  long  splint,  and 
maintained  at  a  proper  length  for  two  or  three  weeks ;  when,  in  conse¬ 
quence  of  a  severe  bronchitic  attack,  it  became  necessary  to  remove  the 
apparatus,  and  the  displacement  speedily  returned.  Whilst  convalescent 
from  this  attack,  the  patient  fell  and  fractured  the  displaced  femur  in 
its  upper  third,  thus  rendering  it  impossible  to  replace  the  bone.  In 
another  case  of  spontaneous  dislocation  of  the  knee,  occurring  in  the 
same  painless  manner,  the  joint  could  not  be  replaced,  and  permanent 
deformity  was  left.  After  reduction  in  similar  cases,  a  splint  or  a 
starched  bandage  should  be  w'orn  for  a  considerable  length  of  time,  so 
as  to  give  a  chance  for  the  ligaments  of  the  joint  to  recover  themselves. 
If  there  be  a  rheumatic  tendency,  it  should  be  removed  by  suitable 
treatment;  and  if  there  be  a  paralytic  condition  of  the  muscles,  elec¬ 
tricity^,  the  endermic  application  of  strychnine,  and  cold  douches  with 
friction,  may  be  advantageous^  employed. 

Congenital  Dislocations  are  occasionally  met  with  in  the  hip, 
shoulder,  wrist,  and  jaw,  and  have  of  late  years  attracted  the  attention 
of  Surgeons  through  the  labors  of  Guerin,  Smith,  Chelius,  Robert,  and 
others.  These  dislocations  are  closely  allied  in  cause  and  nature  with 
other  congenital  deformities  of  the  limbs,  such  as  clubfoot,  etc.  In 
them  there  is  usually  found  arrested  or  imperfect  development  of  some 
portions  of  the  osseous  articular  apparatus.  Whether  this  is  original, 
thus  causing  the  displacement  of  the  bones,  or  consecutive  upon  disuse, 
occasioned  by  spasmodic  action  of  one  set  of  muscles  or  by  paralysis  of 
another,  dependent  on  some  irritation  in  the  nervous  centres,  is  scarcely 
worth  inquiring  here.  In  some  cases  it  would  appear  as  if  faulty  position 
of  the  foetus  in  utero,  or  undue  violence  during  birth,  may  have  occa¬ 
sioned  the  displacement.  These  dislocations  are  probably  incurable,  as 
there  is  always  congenital  defect  of  structure  in  the  articular  ends  of 
the  bones,  or  of  the  socket  into  which  they  are  received. 

VOL.  I _ 26 


402 


SPECIAL  DISLOCATIOXS. 


CHAPTER  XXIII. 

SPECIAL  DISLOCATIONS. 

Dislocations  of  the  Lower  Jaw  are  not  common  accidents.  They 
occur  more  frequently  in  women  than  in  men,  and  have  been  but  very 
seldom  met  with  at  either  extreme  of  life;  but  Nelaton  and  Malgaigne 
relate  cases  occurring  in  edentulous  subjects  of  68  and  12  years  of  age, 
and  Sir  A.  Cooper  has  seen  the  accident  in  a  child,  occasioned  by  another 
bo}"  thrusting  an  apple  into  its  mouth.  These  dislocations  are  most 
frequently  occasioned  by  spasmodic  action  of  the  depressor  muscles  of 
the  jaw — by  opening  the  mouth  too  widely,  as  in  fits  of  laughing,  of 
gaping,  or  in  attempting  to  take  too  large  a  bite.  Occasionally  this 
accident  has  resulted  from  blows  or  kicks  upon  the  chin,  or  from  the 
violent  strain  upon  the  part  in  tooth-drawing,  or  rather  in  digging  out 
stumps  with  an  elevator.  The  mechanism  of  the  dislocation  is  simple. 
When  the  mouth  is  opened,  the  interarticular  fibro-cartilage  with  the 
cond^de  glides  forwards  on  to  the  articular  eminence ;  if  this  movement 
be  continued  too  far,  and  the  external  pterygoid  muscle  contract  forcibly 
at  the  same  time,  the  cond^de  slips  forward  into  the  zygomatic  fossa,  the 
axis  of  the  ramus  being  directed  obliquely  backwards,  and  the  disloca¬ 
tion  being  thus  complete.  In  this  way  both  condyles  may  be  displaced, 
or  onlj^  one.  Maisonneuve  and  Otto  Weber,  by  producing  dislocation 
on  the  dead  bodj^,  have  found  that  the  condyle  lies  in  front  on  the  root 
of  the  zygoma.  The  coronoid  process  rarel}^  reaches  the  malar  bone^ 
but  usually  lies  below  it,  being  completely  surrounded  by  the  tendon  of 
the  temporal  muscle.  From  original  observation,  C.  Heath  confirms  this 
view  of  the  position  of  the  coronoid  process.  The  interarticular  fibro- 
cartilage  is  attached  to  the  condyle,  and  follows  its  movements.  The 
capsular  ligament  is  stretched,  but  not  ruptured ;  the  external  lateral 
ligament  is  tense,  and  passes  from  behind  forward  instead  of  from  before 
backward :  the  internal  lateral  and  stylo-maxillary  ligaments  also 
undergo  stretching,  which  is  increased  by  raising  the  chin.  The  tem¬ 
poral  muscles  are  stretched  according  to  Maisouneuve,  or  partl}^  torn 
according  to  Weber. 

When  the  dislocation  is  Bilateral^  both  condjdes  being  displaced  from 
the  crlenoid  cavities,  the  sigms  are  as  follows.  The  incisor  teeth  of  the 
lower  jaw  are  separated  from  those  of  the  upper  by  a  marked  interval, 
vaiying  from  half  an  inch  to  an  inch  and  a  half ;  the  mouth  consequently 
cannot  be  closed,  but  is  kept  more  or  less  wideH  open.  Deglutition  and 
speech  are  impaired,  the  labial  consonants  not  being  pronounced  ;  there 
is  dribbling  of  the  saliva  over  the  lower  lip ;  the  chin  is  lengthened,  and 
the  lower  line  of  teeth  adv.anced  about  half  an  inch  bej’ond  those  of  the 
upper  jaw ;  the  cheeks  are  fiattened,  and  there  is  a  depression  in  front 
of  the  meatus  auditorius  externus.  There  is  also  an  oblong  prominence 
in  the  temporal  fossa  between  the  qjq  and  ear.  If  the  dislocation  be 
left  unreduced,  the  patient  slowly  regains  some  power  of  movement  over 
the  jaw  ;  he  graduall}’’  approximates  the  lips,  and,  after  a  length  of  time, 
ma}’  even  be  enabled  to  bring  the  lines  of  teeth  into  apposition,  espe- 
eiallj’  posteriorly. 


DISLOCATIONS  OF  THE  LOWER  JAW. 


403 


In  the  Unilateral  dislocation,  where  one  condyle  only  is  displaced,  the 
axis  of  the  lower  jaw  is  directed  towards  the  opposite  side  to  that  on 
which  the  displacement  exists  ;  and  the  general  signs  are  the  same,  but 
in  a  less  marked  degree,  as  those  wliich  are  met  with  when  both  sides 
are  dislocated.  The  hollow  before  the  meatus  on  the  injured  side  is, 
however,  well  marked,  and  serves  to  point  out  the  seat  and  nature  of  the 
displacement,  the  diagnosis  of  which  is  not  always  readily  made:  indeed, 
R.  W.  Smith  states  that  he  has  seen  attempts  at  reduction  applied  to  the 
uninjured  side. 

Sir  A.  Cooper  has  described  a  SubluxoMon  of  the  jaw,  most  frequently 
met  with  in  young  and  delicate  women,  in  which,  in  consequence  of  the 
relaxation  of  the  ligaments,  the  head  of  the  bone  appears  to  slip  for¬ 
wards  upon  the  eminentia  articularis,  whenever  the  mouth  is  opened  at 
all  widely,  as  in  gaping,  laughing,  etc.  It  may  usually  be  ascertained  by 
telling  the  patient  to  put  out  the  tongue.  The  bone  hitches,  as  it  were, 
and  prevents  the  mouth  from  being  shut  at  once.  Most  commonly,  the 
natural  efforts  of  the  patient  are  sufficient  to  return  the  head  of  the  bone 
into  the  glenoid  cavity  with  a  cracking  noise  or  even  a  loud  snap. 

The  Reduction  of  a  dislocated  jaw  is  easily  effected ;  it  being  onl}^ 
necessary  to  push  the  angle  of  the  bone  downwards  and  backwards,  so 
as  to  disentangle  the  coronoid  process  from  under  the  zygomatic  arch,  at 
the  same  time  that  the  chin  is  raised  by  the  Surgeon’s  fingers,  in  order 
that  the  temporal  and  pteiygoid  muscles  may  draw  the  head  of  the  bone 
into  its  proper  position.  The  reduction  is  best  effected  by  the  Surgeon 
standing  before  the  patient  and  applying  his  thumbs,  well  protected  b}’' 
a  thick  napkin,  to  the  molar  teeth  on  each  side,  and  thus  depressing  the 
angle  of  the  jaw  forcibly,  at  the  same  time  that  he  raises  the  chin  by 
means  of  his  fingers  spread  out  and  placed  underneath  it.  The  bone  is 
then  returned  into  its  place  with  so  forcible  a  snap  that  the  thumbs  may 
be  severely  bitten  unless  care  be  taken,  or  they  be  w^ell  covered  up. 
When  one  condyle  only  is  luxated,  the  efforts  at  reduction  should  be 
applied  to  the  injured  side  only.  After  the  reduction,  the  four-tailed 
bandage  should  be  applied,  as  in  cases  of  fracture  of  the  jaw  ;  and  for 
several  days  the  patient  must  not  be  allowed  to  talk,  or  to  eat  any  solid 
food,  lest  the  displacement  return,  wdiich  it  always  has  a  great  tendency 
to  do.  Very  old  dislocations  of  this  bone  ma}’'  be  reduced  by  the  pro¬ 
cess  just  now  described.  Thus,  Strome^^er  replaced  one  at  the  end  of 
thirty-five,  and  Donovan  one  at  the  end  of  ninety-eight  da3's. 

In  the  cases  of  subluxation ^  attention  should  be  paid  to  the  state  of  the 
general  health.  Tonics,  more  particularl^Aron,  should  be  administered; 
good  diet,  the  cold  bath,  and  open-air  exercise  enjoined.  If,  as  frequently 
happens,  there  be  some  tenderness  about  the  temporo-maxillaiy  articula¬ 
tion,  a  series  of  small  blisters  ma}^  be  applied  over  it.  It  is  of  great 
importance  to  prevent  the  habit  of  recurrence  of  the  dislocation.  This 
ma}^  usually  most  conveniently  be  done  by  letting  the  patient  wear  a 
small  silk  cap  fitted  to  the  chin  and  attached  b^^  four  elastic  bands  on 
the  top  of  and  behind  the  head,  as  in  the  case  of  a  fractured  jaw. 

Congenital  Dislocation  of  one  Condyle  of  the  Lower  Jaw  is  a  remark¬ 
able  and  rare  condition,  for  an  acquaintance  with  which  we  are  chiefly 
indebted  to  R.  W.  Smith.  In  this  condition  there  is  a  singular  distortion 
of  countenance.  The  osseous  and  muscular  structures  on  the  dislocated 
side  are  atrophied,  and  the  teeth  of  the  upper  jaw  project  beyond  those 
of  the  lower,  contrary  to  what  occurs  in  the  accidental  dislocation  :  the 
mouth  can  be  closed,  speech  is  perfect,  and  there  is  no  dribbling  of  saliva. 
Congenital  dislocation  of  both  condyles  has  not  yet  been  observed. 


404 


SPECIAL  DISLOCATIONS. 


Dislocations  of  the  Clavicle. — When  we  look  at  the  flat  character 
of  the  sterno-clavicular  articulation  and  the  very  small  and  shallow 
surface  in  the  acromion  upon  which  the  outer  end  of  the  clavicle  is 
received,  and  reflect  on  the  violence  to  which  the  shoulder  is  frequently 
subjected,  we  might  at  first  imagine  that  dislocations  of  the  clavicle 
w'ould  be  amongst  the  most  frequent  forms  of  injury  in  this  region. 
But  this  is  very  far  from  being  the  case.  They  are,  indeed,  rarely  met 
wdth  in  comparison  to  the  frequency  of  fractures  of  this  bone.  This  is 
owing  to  several  causes :  amongst  these  are  the  shortness  and  firmness 
of  the  ligaments  by  which  the  clavicle  is  attached  to  the  sternum  and 
acromium,  and  the  fact  of  any  force  that  is  applied  to  it  being  usually 
received  in  a  line  that  corresponds  to  its  axis,  thus  causing  it  to  be  bent 
or  broken  rather  than  luxated.  The  mobility  of  the  scapula,  also,  has  a 
special  tendency  to  prevent  dislocations  of  the  outer  end  of  the  clavicle, 
the  tw-o  bones  easil}^  moving  together.  Were  it  not  for  this,  the  bone 
would  frequently  be  thrown  off  the  small  flat  articular  surface  of  the 
acromion. 

Dislocations  of  the  clavicle  can  only  be  occasioned  by  violence  applied 
to  the  shoulder  in  such  a  direction,  as  to  drive  the  bone  inw^ards  towards 
the  mesial  line,  at  the  same  time  that  the  scapula  is  fixed. 

Either  the  sternal  or  the  acromial  end  of  the  clavicle  may  be  dislocated, 
and  the  simultaneous  displacement  of  both  even  has  been  observed. 

1.  The  Sternal  End  of  the  Clavicle  may  be  luxated  in  a  direction 
forwards^  backwards^  or  upwards^  being  thrown  before,  behind,  or  above 
the  sternum. 

In  the  dislocation  Forwards^  the  end  of  the  bone  can  be  felt  in  its  new 
position,  the  point  of  the  shoulder  is  approximated  to  the  mesial  line, 
and  the  depressions  above  and  below  the  clavicle  are  strongly  defined. 
It  is  occasioned  by  blows  upon  the  shoulder,  by  bending  this  part  forcibly 
backw^ards,  or  by  violence  applied  to  the  elbow  wdiilst  the  arm  is  raised 
from  the  side.  In  some  cases  it  occurs  spontaneously,  as  a  secondary 
consequence  of  lateral  curvature  or  rotation  of  the  upper  dorsal  vertebrae. 

This  dislocation,  wdiich  is  amongst  the  most  frequent  to  which  the 
clavicle  is  subject,  may  readily  be  reduced  by  pushing  the  shoulder 
outwards  and  bending  it  backw’ards.  The  principal  difficulty  in  the 
treatment  consists  in  preventing  the  return  of  the  displacement,  owing 
to  the  shallowness  of  the  articular  surface  upon  which  the  clavicle 
lodges.  With  this  view  a  pad  and  a  figure-of-8  bandage  must  be  firmly 
applied  upon  the  displaced  end  of  the  bone. 

The  dislocation  Upwards  is  extremely  rare.  The  signs  in  the  two 
recorded  cases  w^ere  so  evident  as  not  to  lead  to  any  difficulty  in  the 
diagnosis  of  the  accident,  the  projection  of  the  sternal  end  of  the  clavicle 
in  its  new  situation  being  at  once  cognizable  to  the  touch.  In  the 
treatment^  a  bandage  and  a  pad,  with  elevation  of  the  elbow,  brought  the 
bone  into  good  position. 

The  dislocation  Backwards  is  not  of  common  occurrence:  though, 
according  to  Nelaton,  there  are  at  least  ten  or  a  dozen  cases  on  record. 
This  luxation  appears  generally  to  have  resulted  from  the  point  of  the 
shoulder  being  driven  upwards,  or  from  the  hand  being  violently  drawn 
forwards.  It  has  also  been  observed  to  result  from  the  direct  pressure 
of  the  clavicle  backwards,  as  by  the  kick  of  a  horse.  In  one  case  under 
my  care,  the  clavicle  was  dislocated  backwards  at  its  sternal  end  by  the 
wheel  of  a  cab  passing  across  the  bone,  and  thus  directly  pressing  it 
backwards,  fracturing  at  the  same  time  the  second  rib,  and  separating 
the  first  from  its  cartilage,  which  was  attached  to  the  clavicle  by  the 


DISLOCATIONS  OF  THE  CLAVICLE. 


405 


unriiptured  costo-clavicular  ligament,  the  traction  on  which  by  the  dislo¬ 
cated  clavicle  had  probably  determined  the  separation  of  the  cartilage 
from  its  rib.  It  has  also  occurred  as  a  secondary  consequence  of  curvature 
of  the  spine. 

The  Signs  are  those  that  usually  attend  a  dislocation  of  the  sternal 
end  of  the  clavicle — shortening  of  the  shoulder,  and  deformity  about  the 
upper  part  of  the  sternum ;  but,  besides  these,  a  special  train  of  S3’'mptoms 
is  occasioned,  by  the  pressure  of  the  displaced  bone  upon  the  trachea, 
oesophagus,  and  vessels  of  the  neck.  Difficulty  in  breatliing  and  swal¬ 
lowing,  with  congestion  of  the  head,  giving  rise  even  to  a  semicomatose 
state,  may  be  produced  to  such  an  extent  as  to  require  removal  of  the 
end  of  the  bone,  as  happened  in  a  case  related  by  Sir  A.  Cooper,  in  which 
the  Surgeon  was  obliged  to  saw  off  the  dislocated  end.  In  some  cases, 
the  end  of  the  bone  is  thrown  upwards  as  well  as  backwards  ;  in  others, 
it  takes  rather  a  downward  direction.  In  one  case  only — that  described 
in  the  preceding  paragraph — have  I  had  an  opportunity  of  examining, 
after  death,  the  condition  of  the  limb  in  dislocation  backwards  of  the 
sternal  end  of  the  clavicle.  In  this  case,  all  the  ligamentous  structures 
around  the  end  of  the  bone  were  torn  through,  with  the  exception  of  the 
costo-clavicular  ligament,  which  had  preserved  its  attachments  unbroken, 
and  had  carried  away  the  cartilage  of  the  first  rib  in  the  direction  of  the 
displaced  clavicle. 

In  the  Treatment  of  this  dislocation,  it  is  easy  to  effect  the  reduction 
of  the  bone  by  making  a  fulcrum  of  the  fist  in  the  axilla,  and  then 
bringing  the  elbow  well  to  the  side,  at  the  same  time  that  an  assistant 
puts  his  knee  between  the  patient’s  shoulders  and  bends  them  back  ;  but 
it  is  difficult  to  retain  the  bone  in  proper  position.  To  fulfil  this  object, 
the  figure-of-8  bandage  tightly  applied  to  the  points  of  the  shoulders,  and 
crossed  over  a  large  pad  placed  in  the  middle  of  the  back,  will  give  the 
most  efficient  support  to  the  part,  the  elbow  being  at  the  same  time  well 
fixed  to  the  side  and  drawn  back. 

2.  The  dislocations  of  the  Outer  End  of  the  Clavicle^  or,  more  correctly’', 
the  dislocations  of  the  acromion  from  the  clavicle,  are  more  commonly 
met  with  than  those  just  described.  The  most 
frequent  accident  of  this  description  is  that  in  which 
the  bone  is  thrown  upon  the  Upper  Surface  of  the 
Acromion^  or  upon  the  Anterior  Part  of  the  Spine 
of  the  Scapula.  In  several  cases  of  this  accident 
which  have  presented  themselves  at  University 
College  Hospital,  there  has  been  no  difficult3"  what¬ 
ever  in  the  diagnosis.  The  prominence  formed  by 
the  displaced  bone  upon  the  upper  surface  of  the 
acromion,  the  narrowing  of  the  distance  from  the 
mesial  line  to  the  point  of  the  shoulder,  the  facility 
of  the  reduction  of  the  dislocation,  and  the  promi- 
nenee  of  the  clavicular  portion  of  the  trapezius 
muscle,  indicate  the  nature  of  the  accident.  (Fig. 

165).  The  of  this  injury  is  by  no  means 

satisfactor3^  Reduction  ma^’  easily  be  effected  by 
raising  the  shoulder,  4rawing  it  backwards,  and 
carrying  it  outwards  by  placing  a  pad  or  the  hand 
in  the  axilla  and  bringing  the  elbow  well  to  the  side.  But,  notwith¬ 
standing  the  facility  of  reduction,  there  is  in  many  cases  a  great  and, 
indeed,  an  unconquerable  tendency"  to  the  return  of  the  displacement. 
This  is  partly  owing  to  the  shallowness  of  the  articular  surface  of  the 


Fig.  IGo. 


on  the  Acromion. 


406 


SPECIAL  DISLOCATIONS. 


acromion,  partly  to  the  tension  of  the  trapezius,  b}"  which  the  acromial 
end  of  the  bone  is  drawn  upwards  and  outwards,  and  in  a  great  degree 
to  the  mobility  of  the  shoulder.  Reduction  is  best  maintained  b}’’  the 
application  of  an  axillary  pad,  and  the  same  method  of  treatment  as  in 
fracture  of  the  clavicle  (Fig.  133). 

In  every  movement  of  the  body  or  neck  there  will  be  found  to  be  a 
tendency  to  rising  upwards  of  the  end  of  the  dislocated  bone,  and  in  the 
majority  of  cases  this  will  be  insurmountable  by  any  mechanical  means 
that  can  be  employed.  It  is  best  limited,  if  not  obviated,  by  a  pad  and 
gutta-percha  plate  laid  on*  the  projecting  clavicle,  and  strapped  tightly 
down  by  a  band  passing  parallel  to  the  arm  and  under  the  flexed  forearm, 
this  being  retained  in  position  by  being  attached  to  a  strap  passed  round 
the  opposite  axilla.  If  the  displacement  continue  to  be  irremediable,  a 
very  useful  arm  will  still  be  left,  only  somewhat  limited  in  its  upper 
movements. 

The  outer  end  of  the  clavicle  has  been  dislocated  Under  the  Acromion 
b}'  the  application  of  direct  violence  to  the  end  of  the  bone.  This  form 
of  displacement  is  very  rare ;  several  instances  have,  however,  been 
mentioned  in  the  journals.  The  diagnosis  is  eas^^,  simple  digital  exami¬ 
nation  pointing  out  the  nature  of  the  accident ;  and  the  treatment  must 
be  conducted  in  the  same  way  as  that  of  fractured  clavicle. 

The  acromial  end  of  the  clavicle  has  been  known  to  be  displaced 
Underneath  the  Coracoid  Process,  Here,  also,  simple  examination  and 
the  clavicular  bandage  suflSce  for  diagnosis  and  treatment. 

The  only  instances  of  Simultaneous  Dislocation  of  both  ends  of  the 
Clavicle  with  which  I  am  acquainted  have  been  reported  hy  Richerand 
and  Morel-Lavallee  and  Xorth  of  Brooklyn. 

Dislocation  of  the  Scapula. — The  Lower  Angle  and  Dorsal  Bor¬ 
der  of  the  Scajnda  is  occasionally  the  seat  of  a  very  remarkable  kind  of 
displacement,  in  consequence  of  which  it  projects  at  a  considerable  angle 
from  the  trunk,  giving  a  winged  appearance  to  the  back.  The  cause  of 
this  peculiar  displacement  is  obscure  :  by  some  it  is  considered  to  be 
dependent  upon  the  bone  slipping  away  from  under  the  posterior  edge 
of  the  latissimus  dorsi  muscle  ;  by  others,  and  apparently  with  more 
reason,  it  is  regarded  as  owing  to  paralysis  of  the  serratus  magnus. 
"Whether  this  be  dependent  upon  some  morbid  condition  of  the  muscle 
itself,  as  Jacob  supposes,  or  on  a  paralyzed  state  of  the  long  thoracic 
nerve,  as  Nelaton  thinks,  can  scarcelj^  be  determined.  In  such  cases  as 
these,  I  have  seen  some  benefit  derived  from  the  endermic  application  of 
strychnine  on  a  blistered  surface,  and  afterwards  support  b}’"  means  of 
a  properly  constructed  apparatus. 

Dislocations  of  the  Shoulder-joint  occur  far  more  frequently 
than  those  of  an}"  other  articulation.  Their  pathology  and  treatment  have 
been  so  clearly  elucidated  by  Sir  A.  Cooper,  that  there  is  little  left  for 
subsequent  writers  but  to  follow  the  descriptions  given  by  that  great 
Surgeon ;  though  several  of  the  modern  French  Surgeons,  especially 
Telpeau,  Malgaigne,  and  Goyrand,  have  thrown  some  new  light  on  the 
subject.  The  reason  of  the  frequency  of  these  dislocations  is  to  be  found 
in  the  shallowness  of  the  glenoid  cavity,  the  large  size  and  rounded 
shape  of  the  head  of  the  humerus,  and  the  weakness  of  the  ligaments  ; 
but,  above  all,  in  the  extent  and  force  of  the  movements  to  which  the 
joint  is  subjected.  These  displacements  indeed  would  be  much  more 
frequent  than  they  even  are,  w-ere  it  not  for  the  protection  afforded  to 
the  joint  by  the  osseous  and  ligamentous  arch  formed  by  the  coracoid 
process  and  acromion  with  their  ligaments,  the  great  strength  of  the 


DISLOCATIONS  OF  THE  SHOULDER- JOINT. 


407 


capsular  muscles  and  their  close  connection  with  the  joint,  and  the  sup¬ 
port  given  by  the  tension  of  the  long  head  of  the  biceps  over  its  weakest 
part ;  but  the  principal  obstacle  to  dislocation  is  the  mobility  of  the 
scapula,  enabling  all  movements  communicated  to  the  hand  and  arm  to 
react  upon  that  bone. 

The  Signs  of  dislocation  of  the  shoulder-joint  are  sufficiently  obvious, 
varying,  however,  according  to  the  nature  of  the  injuiy.  In  all  cases 
there  are  six  common  signs,  viz.,  1,  a  flattening  of  the  shoulder ;  2,  a 
hollow  under  the  acromion  ;  3,  an  apparent  projection  of  this  process, 
with  hollow  tension  of  the  deltoid ;  4,  the  presence  of  the  head  of  the 
bone  in  an  abdominal  situation  ;  5,  rigidity ;  and  6,  pain  about  the 
shoulder. 

The  shoulder-joint  is  susceptible  of  four  dislocations.  Of  these,  ac¬ 
cording  to  Sir  A.  Cooper,  three  are  complete,  and  the  fourth  partial.  I 
think,  however,  that  on  examination  it  will  be  found  that  the  so-called 
partial  dislocation  is  in  reality  a  complete  one.  The  directions  in  which 
the  head  of  the  humerus  may  be  thrown  are — 1,  inwards  and  slightly 
downwards  beneath  the  coracoid  process — Subcoracoid  (Fig.  168) ;  for¬ 
wards  and  inwards  beneath  the  clavicle — Subclamcidar  (Fig.  167); 
3,  backwards  and  downwards  under  the  spine  of  the  scapula — Subspinous 
(Fi^.  169);  4,  downwards  and  slightly  inwards  under  the  glenoid  cavity 
— Subglenoid  (Fig.  166).  Thus  three  dislocations  are  more  or  less 
inwards,  one  only  being  backwards  or  outwards. 


Fig.  166.  Fig.  167.  Fig.  168.  Fig.  169. 


DISLOCATIONS  OF  THE  HEAD  OF  THE  HCMERCS. 

Subglenoid.  Subclavicular.  Subcoracoid.  Subspinous. 


1.  Subcoracoid  Dislocation. — In  the  case  of  incomplete  dislocation 
reported  by  Sir  A.  Cooper,  the  head  of  the  bone  was  found  to  be  thrown 
out  of  the  glenoid  cavity,  lying  under  the  coracoid  process  upon  the 
anterior  part  of  the  neck  of  the  scapula  (Fig.  168)  ;  the  capsular  muscles 
were  not  torn,  but  the  long  head  of  the  biceps  had  been  ruptured.  The 
description  given  by  Sir  A.  Cooper,  and  the  illustrative  plate  in  his  work 
on  Dislocations.,  appear  to  point  to  a  form  of  injuiy  of  the  shoulder-joint 
which  has  of  late  3’ears  been  specially  described  by  the  French  surgeons 
as  a  variety  of  the  dislocation  downwards;  that  form  of  displacement, 
indeed,  which  b}"  Bo3’er  has  been  described  as  the  dislocation  “  inwards,” 
b3’  Malgaigne  as  the  “subcoracoid”  luxation,  and  b3’  Velpeau  as  the 
“  subscapular”  dislocation;  in  which  the  head  of  the  humerus  is  placed 
in  front  of  the  neck  of  the  scapula,  and  underneath  the  subscapular 
muscle.  In  this  dislocation  the  head  of  the  bone,  instead  of  being  thrown. 


408 


SPECIAL  DISLOCATIONS.  . 


Fig.  170. 


as  in  the  subglenoid,  downwards  and  slightly  inwards,  is  thrown  inwards 
either  directly  or  slightly  downwards  as  well.  Wh}^  Sir  A.  Cooper 
described  this  as  a  2^o.rtial  dislocation,  I  do  not  understand  ;  for  not  only 
was  there  rupture  of  the  capsule  and  of  the  long  tendon  of  the  biceps, 
but  the  woodcut  at  page  401  of  the  last  edition  of  his  work  shows  clearly 
that  the  head  of  the  bone  had  formed  a  new  articular  cavit}^  for  itself  in 
the  subscapular  fossa,  being  apparently  thrown  out  of  the  glenoid 
cavity. 

There  is  here  less  deformity  than  in  the  other  luxations,  the  acromion 
not  forming  so  distinct  a  projection  (Fig.  170).  The  limb  is  usually 

somewhat  lengthened,  but  at  times  is  actually 
shortened,  the  elbow  being  usually  carried  back¬ 
wards  and  alwa^^s  slightly  away  from  the  side ; 
the  head  of  the  bone  is  placed  deeply  in  the 
upper  and  inner  part  of  the  axilla,  and  cannot 
alwa3"S  be  veiy  distinctly"  felt,  owing  to  its  being 
thickly  covered  with  soft  parts,  by  the  coraco- 
brachialis  as  well  as  by  the  pectorals  ;  rotation 
of  the  arm  and  elevation  of  the  elbow  being  usu¬ 
ally  required  in  order  that  it  may  be  detected. 

2.  In  the  dislocation  Forwards^  or  the  Suh- 
clavicular  (Fig.  167),  the  head  of  the  bone  is 
thrown  on  the  inner  side  of  the  coracoid  pro¬ 
cess,  ly’ing  upon  the  second  and  third  ribs  under 
the  pectoral  muscles,  and  immediately  below  the 
clavicle.  This  dislocation  is  merely  an  increased 
degree  of  the  preceding  one,  the  head  of  the 
bone,  which  at  first  lies  under  the  coracoid  pro¬ 
cess,  being  readily  drawn  inwards,  so  as  to  be 
placed  to  the  inner  side  of  this  process  under 
the  clavicle.  In  these  cases  the  capsular  muscles  are  much  stretched  or 
torn.  In  a  case  recorded  by  Curling,  the  infraspinatus  and  subscapu- 
laris  muscles  were  torn  away  from  the  tubercles  of  the  humerus,  and  the 
teres  minor  partially  lacerated  ,  the  capsule  being  completely  separated 
from  the  neck  of  the  bone,  which  pressed  forcibly  upon  the  axillary  ves¬ 
sels  and  nerves.  In  three  cases  which  I  have  had  an  opportunity  of  dis¬ 
secting  and  examining  after  death,  the  great  tubercle  was  torn  away"  from 
the  head  of  the  bone,  with  much  laceratian  of  the  capsule  and  extensive 
extravasation,  but  the  external  rotator  muscles  were  not  ruptured  in  two 
instances;  whilst  in  the  third  the  supraspinatus,  the  infraspinatus,  and 
the  teres  minor,  were  all  torn  across  near  the  insertions  into  the  humerus. 
In  fact,  in  these  cases  it  appears  to  be  a  question  of  strength  between 
muscle  and  bone ;  either  the  muscles  are  torn  across,  or  the  great  tubercle, 
into  which  they^  are  inserted,  is  torn  away  from  the  shaft  of  the  bone, 
leaving  its  attached  muscles  unruptured. 

In  this  dislocation,  the  head  of  the  humerus  can  be  felt  and  seen  under 
the  pectoral  muscles  beneath  the  clavicle ;  the  arm  is  shortened,  the  axis 
of  the  limb  being  directed  towards  its  head,  and  the  elbow  is  a  good  deal 
separated  from  the  side  and  thrown  back. 

3.  In  the  dislocation  Backivards^  or  the  Subspinous  (Fig.  169),  the 
head  of  the  humerus  lies  behind  the  glenoid  cavity,  and  below  the  spine 
of  the  scapula,  between  the  infraspinatus  and  teres  minor  muscles.  Key 
found  the  tendon  of  the  subscapularis  torn  across,  together  with  the 
internal  portion  of  the  capsular  ligament ;  the  supraspinatus  and  the 
long  head  of  the  biceps  being  stretched,  but  not  ruptured. 


Subcur,  cnid  Dislocation  of 
Humerus. 


DISLOCATIONS  OF  THE  SHOULDER- JOINT. 


409 


When  the  head  of  the  hone  is  dislocated  below  the  spine  of  the  scapula, 
it  can  be  felt  and  seen  there,  more  especially  when  the  arm  is  rotated. 
The  axis  of  the  limb  is  altered,  being  directed  backwards  nearlj^  hori¬ 
zontally  ;  the  elbow  is  raised  from  the  side,  to  wliich  it  cannot  be  approxi¬ 
mated,  and  is  carried  forwards  and  somewhat  downwards. 

4.  In  the  dislocation  Downivards^  or  the  Subglenoid  (Fig.  Ill),  the 
head  of  the  bone  lies  in  the  axilla,  resting  against  the  inferior  costa  of 
the  scapula  below  the  glenoid  cavity,  and 
lodged  between  the  subscapular  muscle  and 
the  long  portion  of  the  triceps.  In  it  the  ten¬ 
don  of  the  subscapular  muscle  is  commonly 
torn  near  its  insertion  into  the  lesser  tubercle 
of  the  humerus,  and  the  capsular  ligament  is 
largely  lacerated.  The  supraspinatus  muscle 
may  also  be  torn  through,  or  a  portion  of  the 
great  tubercle  of  the  humerus  detached,  and 
the  rest  of  the  capsular  muscles  put  greatly  on 
the  stretch.  The  axillary  artery  and  plexus 
of  nerves  are  compressed  and  stretched  by  the 
dislocated  head  of  the  bone,  so  that  a  severe 
numb  pain  is  commonly  exjDerienced  in  the 
hand  and  arm.  The  compression  of  the  artery 
is  so  great,  that  the  circulation  through  the 
limb  is  completely  arrested.  This  I  saw  re¬ 
markably  illustrated  in  a  case  of  dislocation 
downwards  of  the  head  of  the  humerus,  with  a  severe  lacerated  wound  of 
tlie  forearm,  dividing  the  radial  and  ulnar  arteries.  So  long  as  the 
dislocation  remained  unreduced  no  hemorrhage  took  place ;  but  when 
the  head  of  the  bone  was  replaced,  the  injured  arteries  bled  freel}''. 

The  head  of  the  bone  can  usually  be  readily  felt  in  the  axilla,  at  its 
anterior  and  under  part ;  the  arm  is  lengthened  to  the  extent  of  about  an 
inch,  the  forearm  is  usually  somewhat  bent,  and  the  fingers  are  often 
numbed,  in  consequence  of  the  pressure  of  the  head  of  the  bone  on  the 
axillary  plexus.  The  elbow  is  separated  from  the  trunk  and  carried 
somewhat  backwards,  but  can  be  approximated  to  the  side.  If  the  head 
of  the  bone  cannot  be  felt  in  the  axilla,  its  presence  there  may  be  ascer¬ 
tained,  as  Cooper  directs,  by  raising  the  elbow,  when  it  at  once  becomes 
perceptible. 

In  a  case  which  occurred  to  Cleland  of  Galway,  the  arm  was  thrown 
up  so  as  to  reach  above  the  patient’s  head.  This  patient  was  lame  and 
used  crutches :  and  Cleland  supposes  that  one  of  the  crutches,  having 
slipped,  acted  as  a  fulcrum  in  such  a  way  as  to  cause  the  weight  of  the 
bod}’-  in  falling  to  overcome  the  tendency  of  the  latissimus  dorsi  and 
pectoralis  major  muscles  to  draw  the  arm  towards  the  side.  Reduction 
was  readily  effected. 

It  appears  to  me  that  the  only  dislocation  of  the  humerus  to  which 
the  term  Partial  is  strictly  applicable,  is  that  which  has  been  described 
by  Soden,  in  which  the  long  tendon  of  the  biceps  is  displaced  from  its 
groove  or  ruptured,  and  the  head  of  the  bone  is  thrown  upwards  and 
forwards  under  the  coracoid  process,  but  not  out  of  the  glenoid  cavit3^ 
It  is  to  this  form  of  displacement  also  that  Callaway  seems  disposed  to 
confine  the  term  partial. 

In  this  partial  dislocation  the  signs  do  not  appear  to  be  very  evident. 
In  Soden’s  case  there  was  slight  flattening  of  the  outer  and  posterior 
parts  of  the  joint,  and  the  head  of  the  bone  appeared  to  be  drawn  higher 


Fig.  171. 


410 


SPECIAL  DISLOCATIONS. 


up  in  the  glenoid  cavity  than  usual.  There  was  great  pain  induced  by 
any  movement  of  the  biceps  muscle ;  and,  on  attempting  any  overhand 
motions,  the  head  of  the  bone  became  locked  by  the  acromion. 

Causes. — Dislocations  of  the  shoulder-joint  are  in  almost  all  cases  the 
result  of  falls  upon  the  hand  or  elbow;  the  particular  variety  of  disloca¬ 
tion  depending  upon  the  direction  of  the  shock  communicated  to  the 
arm,  and  the  position  of  the  limb  at  the  time  of  receiving  it.  On  this 
account  we  almost  invariably  find  the  displacement  in  a  direction 
inwards  and  downwards.  When  a  person  saves  himself  in  falling  with 
his  arms  widely  stretched  out,  the  head  of  the  bone  is  driven  with  all 
the  force  of  a  long  lever  against  the  lower  and  inner  portion  of  the  cap¬ 
sule,  which,  being  ruptured,  in  this  its  weakest  part,  allows  the  bone  to 
be  thrown  upon  or  to  the  inside  of  the  inferior  costa  of  the  scapula,  and 
thus  into  the  axilla.  When  the  patient  falls  upon  his  elbow,  the  inner 
part  of  the  joint  is  still  acted  on ;  but,  the  leverage  not  being  so  great, 
the  head  of  the  bone  is  thrown  upwards  or  forwards  under  the  clavicle. 
This  dislocation  is  also  often  the  result  of  direct  violence  applied  to  the 
shoulder. 

The  dislocation  backwards  can  only  take  place  if  the  arm  receive  the 
shock  at  the  time  when  it  is  stretched  across  the  chest.  As  this  is  an 
unusual  position  for  any  injury  to  be  received  in,  this  dislocation  is 
proportionately  rare.  An  obstacle  to  this  displacement  may  also  be 
found  in  the  great  strength  of  the  outer  portion  of  the  capsule  of  the 
joint,  as  compared  with  the  inner. 

Relative  Frequency. — Sir  A.  Cooper  states  that  the  dislocation  “into 
the  axilla”  is  the  most  frequent  form  of  accident.  This  opinion  is  sup¬ 
ported  by  that  of  most  English  Surgeons.  But  Malgaigne,  and  more 
recently  Flower,  have  expressed  the  opinion  that  the  subcoracoid  is  the 
most  common  form  of  this  accident.  Flower,  who  has  very  ably  inves¬ 
tigated  this  subject,  finds  that  of  forty-one  specimens  in  the  different 
London  Museums,  thirty-one  are  undoubtedly  subcoracoid,  and  that,  of 
fifty  recent  cases  of  which  he  has  cognizance,  forty-four  were  of  this 
form.  jSText  in  order  of  frequency  comes  the  subglenoid.,  and  then  the 
sub  clavicular.,  which  is  somewhat  rare.  I  believe  that  the  subclavicular 
is,  as  it  were,  an  exaggerated  degree  of  the  subcoracoid;  the  continu¬ 
ance  of  the  same  force,  whether  mechanical  or  muscular,  which  had 
thrown  or  drawn  the  head  of  the  bone  to  the  inner  side  of  the  coracoid 
process,  carrying  it  upwards  and  inwards  under  the  centre  of  the  clavicle. 
The  displacement  of  the  head  of  the  bone  under  the  spine  of  the  scapula 
is  so  rare  that  Sir  A.  Cooper  met  with  two  cases  only  of  it ;  several 
cases  have  occurred  at  the  University  College  Hospital,  which  were 
reduced  without  difficulty. 

Diagnosis. — Dislocations  of  the  humerus  may  readily  be  diagnosed 
ivom  fractures  of  the  anatomical  and  surgical  neck  of  the  bone,  by  the 
existence  of  the  signs  which  are  common  to  all  luxations,  and  by  the 
absence  of  crepitus.  In  fractures  in  this  situation,  also,  the  glenoid 
cavity  always  continues  to  be  occupied  by  the  head  of  the  bone.  The 
existence  of  crepitus,  of  slight  shortening,  but  little  alteration  in  the  axis 
of  the  limb,  and  no  correspondence  between  this  and  the  position  of  its 
head,  are  additional  signs  of  value  in  establishing  the  diagnosis.  The 
nature  of  the  accident  that  occasions  the  injury  is  often  an  important 
element  in  the  diagnosis.  Fractures  of  the  upper  end  of  the  humerus 
can  only  occur  from  direct  violence  applied  to  the  shoulders.  Dislo¬ 
cations,  on  the  other  hand,  are  almost  invariably  the  result  of  indirect 
violence  applied  to  the  hand  or  elbow.  Hence  the  injury  resulting  from 


REDUCTION  OF  DISLOCATED  HUMERUS. 


411 


a  fall  or  blow  on  the  shoulder  itself  is  almost  always  a  fracture ;  that 
from  a  fall  on  the  hand  or  blow  on  the  elbow  a  dislocation  of  the  hu¬ 
merus.  Paralysis  of  the  deltoid  from  a  blow  on  the  circumflex  nerve 
may  simulate  a  dislocation,  the  shoulder  being  flattened  and  the  acro¬ 
mion  projecting:  but  here  the  mobility  of  the  joint,  and  the  presence  of 
the  head  of  the  bone  in  the  glenoid  cavity,  establish  the  absence  of  dis¬ 
location. 

Tlie  Reduction  of  a  dislocated  humerus  may  be  conducted  on  three 
different  plans: — by  the  heel  in  the  axilla;  by  the  knee  ;  or  by  drawing 
the  arm  upwards.  Whichever  plan  is  adopted  the  patient  should,  if 
strong,  be  put  under  the  influence  of  chloroform ;  when  his  muscles  are 
paralyzed  by  this  agent  but  little  force  is  required  to  effect  the  reduc¬ 
tion,  the  Surgeon’s  unaided  strength  usually  sufficing  for  this  purpose. 
If  more  power,  however,  should  be  required  than  he  can  exercise,  exten¬ 
sion  may  be  made  by  assistants  drawing  upon  a  towel  .properly  fixed 
round  the  lower  end  of  the  humerus,  or  else  by  the  pulleys  attached  to 
the  same  part  of  the  limb. 

1.  The  reduction  of  the  dislocation  bij  the  heel  of  the  axilla^  is  certainly 
the  easiest  procedure  in  ordinary  cases.  In  adopting  this  plan  the 
patient  is  laid  upon  his  back  upon  a  low  bed  or  couch;  the  Surgeon, 
seating  himself  upon  the  edge  of  this  on  the  same  side  as  the  dislocated 
arm,  takes  the  limb  by  the  wrist,  and,  fixing  one  foot  firmly  upon  the 
ground,  places  the  other,  merel}'’  covered  with  the  stocking,  well  up 
into  the  axilla,  so  that  the  heel  may  press  against  the  lower  border  of 


Fig.  172. 


Keduction  of  Dislocated  Shoulder-joint,  by  the  Heel  in  the  Axilla. 


the  scapula,  and  the  ball  of  the  foot  act  upon  the  humerus  (Fig.  172). 
He  then  draws  the  limb  steadily  downwards,  and,  when  it  is  disengaged 
to  a  sufficient  extent,  brings  the  hand  across  the  patient,  using  his  foot 
as  a  fulcrum,  by  which  the  head  of  the  bone  may  be  reduced  by  being 
pushed  upwards  and  outwards.  This  mode  of  reduction  is  especially 
serviceable  in  ordinary  dislocations  into  the  axilla,  and  in  those  under 
the  clavicle.  In  the  latter,  however,  it  will  be  necessaiy  to  draw  the 
arm  more  obliquely  downwards  and  backwards,  and  to  press  the  foot 


412 


SPECIAL  DISLOCATIONS. 


somewhat  forwards  upon  the  head  of  the  bone,  after  it  has  been  disen¬ 
gaged  by  being  brought  below  the  coracoid  process. 

2.  The  reduction  by  the  knee  in  the  axilla  is  precisely  the  same  in 
principle  as  the  last,  though  not  by  any  means  so  good  a  plan  ;  the  knee 
being  too  large,  and  not  following  the  movements  of  the  humerus  so 
readily  as  the  foot.  In  effecting  the  redaction  by  this  means,  the  patient 
is  seated  on  a  chair ;  and  the  Surgeon,  standing  by  his  side  and  resting 
one  foot  upon  the  seat,  places  his  knee  in  the  axilla.  He  then  seizes  the 
patient’s  arm  above  the  elbow  with  his  right  hand,  and,  steadying  the 
acromion  with  his  left,  draws  the  limb  well  down,  and  brings  it  across 
the  knee :  the  head  of  the  bone  is  thus  reduced. 

3.  In  some  cases  reduction  is  easily  effected  by  laying  the  patient  on 
his  back,  when  the  Surgeon,  sitting  behind  him,  raises  the  arm  perpen¬ 
dicularly  by  the  side  of  the  head,  at  the  same  time  fixing  the  acromion. 
The  head  of  the  bone  is  thus  brought  directly  upwards  into  the  glenoid 
cavity. 

If  the  patient  be  very  muscular,  or  the  dislocation  of  old  standing,  it 
may  be  necessary  to  have  recourse  to  the  pulleys  in  order  to  effect  reduc¬ 
tion.  In  applying  these  the  scapula  must  be  firmly  fixed,  the  counter 
extension  being  made  by  passing  the  patient’s  arm  through  a  slit  in  the 
middle  of  a  jack-towel,  which  should  be  fixed  firmly  to  a  hook  or  staple 
in  ‘the  wall.  The  extending  force  may  then  be  applied  immediately 
above  the  elbow ;  and  traction  being  mad^  slowly  and  steadily  in  the 
direction  of  the  axis  of  the  limb.  The  head  of  the  bone  should  be 
directed  to  the  glenoid  cavity  by  the  pressure  of  the  Surgeon’s  hands, 
so  soon  as  it  has  come  on  a  level  with  it.  In  this  way  dislocations  of 
the  humerus  of  many  weeks’  or  even  months’  standing  have  been  suc¬ 
cessfully  reduced ;  but  in  employing  these  powerful  means,  especially 
under  the  influence  of  chloroform,  the  Surgeon  should  always  bear  in 
mind  that,  unless  care  be  taken,  serious  mischief,  even  laceration  of  the 
axillary  artery,  may  result. 

After  dislocation  of  the  humerus  has  been  reduced,  the  limb  should 
be  firmly  fixed  to  the  side  for  at  least  two  weeks.  It  may  then  be  put 
in  a  sling  for  another  fortnight ;  and  at  the  end  of  a  month,  passive 
motion,  with  friction,  may  be  employed.  If  inflammation  occur  about 
the  joint,  recourse  may  be  had  to  leeches  and  evaporating  lotions. 

After  reduction,  there  is  a  tendency  for  the  head  of  the  bone  to  be 
drawn  upwards  and  outwards  under  and  against  the  acromion,  owing 
evidently  to  the  deltoid  and  coraco-brachialis  muscles  not  being  coun¬ 
terbalanced  in  their  actions  by  those  that  have  been  separated  from  the 
head  of  the  bone. 

Compound  Dislocation  of  the  Head  of  the  Humerus  is  a  rare  accident. 
I  have,  however,  seen  two  cases  of  it,  and  in  two  directions :  down- 
w'ards — Subglenoid^  and  inwards — Subcoracoid.  In  both  cases  reduc¬ 
tion  was  effected,  and  the  patients  did  well.  In  it,  even  though  the 
injury  be  extensive,  it  is  better  not  to  amputate  if  the  axillary  vessels 
and  nerves  be  uninjured.  The  limb  may  be  saved  by  reducing  the  bone 
at  once ;  after  this  the  wound  should  be  closed  and  dressed  lightly,  and 
kept  cool  by  constant  irrigation.  If  the  axillary  artery  be  ruptured, 
either  completely  or  through  its  inner  and  middle  coats,  obstruction  to 
the  arterial  circulation  of  the  arm  will  ensue,  and  amputation  must  be 
performed  through  the  articulation. 

Complications. — A  Simple  Dislocation  of  the  Head  of  the  Humerus^ 
with  Rupture  of  the  Axillary  Artery  and  the  formation  of  a  diffused 
axillary  aneurism,  is  a  condition  of  things  as  serious  as  it  is  fortunately 


OLD  DISLOCATIONS  OF  THE  HUMERUS. 


413 


rave.  In  a  case  of  this  kind,  R.  Adams,  after  reducing  the  dislocation, 
ligatured  the  subclavian  artery,  the  patient  recovering;  and  this  would 
be  the  proper  practice  to  pursue  in  similar  cases. 

A  very  serious  accident,  and  apparentl}’^  difficult  to  treat,  consists  in 
the  complication  of  a  Dislocation  of  the  Humerus  with  Fracture  through^ 
the  Epiphysis  of  the  displaced  bone.  A  case  of  this  kind,  to  which  I 
was  called,  is  described  at  page  400. 

When  the  dislocation  is  complicated  with  a  Fracture  of  the  Shaft  of 
the  Bone^  it  should  be  reduced  at  once  by  putting  the  fracture  up  veiy 
firmly,  and  then  attempting  the  reduction  by  one  of  the  usual  methods. 
In  the  cases  to  which  I  have  already  referred  (p.  400),  I  succeeded  with¬ 
out  difficulty  b}"  means  of  the  heel  in  the  axilla.  The  fracture  must 
then  be  treated  by  lateral  splints. 

Congenital  Dislocations  of  the  Shoulder-joint  have  of  late  years 
attracted  attention.  R.  W.  Smith  has  ascertained,  by  goost-mortem  ex¬ 
amination,  the  existence  of  two  varieties  of  this  condition — the  Subcora¬ 
coid  and  Suhacromiat  luxations.  In  these  there  is  "wasting  of  the 
muscles  of  the  shoulder  and  arm,  the  motions  of  which  are  extremely 
limited,  whilst  those  of  the  scapula  are  preternaturally  great.  The 
condition  of  the  bones  is  also  remarkable.  In  a  case  of  congenital 
subacromial  luxation  of  both  shoulders,  there  was  no  trace  of  a  glenoid 
cavity ;  but  a  well-formed  socket  existed  on  the  outer  side  of  the  neck 
of  the  scapula,  receiving  the  head  of  the  humerus,  which  was  small  and 
distorted.  These  dislocations,  though  existing  from  birth,  usually 
become  more  marked  as  age  advances,  but  are  necessarily  irremediable, 
in  consequence  of  the  malformation  of  the  osseous  structures  and  the 
wasting  of  the  muscles. 

Old  Unreduced  Dislocations  of  the  Head  of  the  Humerus  are  not 
unfrequently  met  with.  In  the  majorit}^  of  these  cases  there  is  a  con¬ 
siderable  amount  of  pain  and  immobility  about  the  shoulder  at  first ; 
but  after  a  time  the  head  of  the  humerus  forms  a  new  bed  for  itself,  and 
the  movements  of  the  arm  become  freer  and  less  painful,  so  that  even- 
tuall}'-  a  limb  useful  for  all  except  the  overhead  movements  will  result. 

In  cases  of  old  dislocation  of  the  head  of  the  humerus,  the  question 
as  to  the  advisability  of  attempting  reduction  always  presents  itself  to 
the  Surgeon.  As  a  general  rule  this  should  always  be  attempted  under 
chloroform,  in  accordance  with  the  principles  laid  dowui  at  p.  396,  if 
only  a  few'  weeks  have  elapsed  from  the  time  of  the  accident,  and  then 
it  will  usually  be  attended  with  success.  Reduction  has  been  effected 
in  many  cases  at  much  later  periods  than  this ;  by  Brodhurst,  after 
twenty-five  w^eeks  had  elapsed  ;  by  Smith  (U.  S.),  after  six,  seven,  eight, 
nine,  and  ten  months  ;  by  Malgaigne,  after  eight  months ;  by  Caron  du 
Pillard,  after  six  months ;  and  by  Sedillot,  after  a  year.  By  the  use  of 
the  subcutaneous  division  of  the  muscles,  etc.,  Dieffenbach  is  said  to 
have  succeeded  in  reducing  a  dislocation  of  the  shoulder  after  it  had 
existed  two  years.  In  maiw  cases,  however,  at  a  much  earlier  period 
than  these,  the  Surgeon  will  fail,  notwithstanding  the  most  persevering 
attempts  at  reduction ;  and  in  others  again  certain  accidents  have  occur¬ 
red,  which  every  Surgeon  should  bear  in  mind,  so  as  to  render  him 
cautious  in  his  proceedings. 

The  Accidents  that  have  occurred  in  attempts  at  reducing  old-standing 
dislocation’s  of  the  head  of  the  humerus  are  such  as  may  arise  either 
from  the  employment  of  an  undue  amount  of  force,  from  the  separation 
of  the  head  of  the  humerus  from  the  adhesions  that  it  has  contracted 
in  its  new  situation,  or  from  pathological  changes  in  the  limb  itself. 


414 


SPECIAL  DISLOCATIONS. 


Among  the  first  are  laceration  and  bruising  of  the  skin,  subcutaneous 
areolar  tissue,  and  muscles,  with  extravasation  of  blood ;  amongst  the 
latter  are  fracture  of  the  humerus,  laceration  of  the  axillary  vessels  and 
nerves,  and  avulsion  of  the  limb. 

Fracture  of  the  humer'us  has  occurred  in  the  practice  of  many  Sur¬ 
geons  of  eminence.  It  has  happened  to  Petit,  Pott,  Larrey,  Berard, 
Denonvilliers,  and  others.  The  surgical  neck  of  the  bone  appears  to 
have  usually  given  wa}’ ;  and  the  accident  has  not  occurred  so  much 
from  forcible  extension,  as  in  carrying  the  arm  across  the  chest  so  as  to 
tilt  the  head  of  the  bone  into  its  place,  -when  the  shaft  becomes  exposed 
to  fracture  b3^  pressure  in  a  transverse  direction.  Such  an  accident 
necessarily'  prevents  all  further  attempts  at  reduction. 

Fracture  of  the  ribs,  by' the  pressure  exercised  against  the  wall  of  the 
chest,  is  supposed  to  have  occurred  in  some  cases. 

The  extravasation  of  a  large  quantity^  of  blood  into  the  areolar  tissue 
of  the  axilla  has  occasionally'  occurred,  without  any'  evidence  of  the  rup¬ 
ture  of  one  of  the  main  vessels.  In  these  cases  the  swelling  has  gradu¬ 
ally^  subsided  under  the  employment  of  ordinary  treatment,  by  rest  and 
evaporating  lotions. 

More  serious  by  far  than  this  is  the  rupture  of  one  of  the  large  blood¬ 
vessels  in  the  axilla.  This  may’-  either  happen  from  the  pressure  of  the 
Surgeon’s  heel,  as  in  a  case  reported  by  Hamilton,  in  which  an  attempt 
was  made  to  reduce  a  dislocation  of  old  standing  by  this  means  ;  the 
Surgeon  unfortunately  forgetting  to  remove  his  boot,  and  thus  contusing 
and  lacerating  the  arteiy.  Or  it  may  occur  from  tlie  humerus  having 
become  adherent  to  the  vessel,  and  lacerating  this  when  torn  away'.  The 
instances  on  record  of  laceration  of  the  axillary  arteiy,  and  the  conse¬ 
quent  formation  of  a  diffuse  traumatic  aneurism  in  the  axilla,  in  the 
reduction  of  old  dislocations,  are  so  numerous — there  being  at  least 
twelve  cases  in  the  records  of  surgery — as  to  act  as  a  warning  to  the 
Surgeon  not  to  employ'  too  much  force. 

In  the  great  majority  of  these  cases — in  at  least  ten  out  of  the  twelve 
— the  diffused  traumatic  aneurism  appeared  immediately'  after  the  em¬ 
ployment  of  forcible  and  long-continued  extension.  In  the  remaining 
two  instances,  the  aneurism al  tumor  did  not  appear  until  after  the  lapse 
of  time.  In  Hiq^uy'tren’s  case  a  w'oman,  sixty'  y'ears  of  age,  had  a  dislo¬ 
cation  into  the  axilla  of  six  weeks’  standing  reduced.  Two  or  three 
months  after  this,  a  tumor  appeared  in  the  armpit.  This  was  mistaken 
for  an  abscess,  and  opened  ;  arterial  hemorrhage  ensued,  and  the  patient 
died  on  the  eighth  day,  from  secondary  bleeding.  In  Nelaton’s  case 
the  patient,  also  an  old  woman,  had  a  subglenoid  dislocation  which  was 
easily'  reduced.  But  an  aneurism  appeared  in  the  axilla,  which,  three 
months  after  the  reduction,  compelled  that  distinguished  Surgeon  to  tie 
the  subclavian.  Both  these  aneurisms  were  probably  circumscribed. 

Dupuytren’s  case  was  not  the  only  one  in  which  the  fatal  mistake  was 
committed  of  opening  the  aneurism  in  the  axilla — the  same  was  done  by 
Pelletan,  who  mistook  the  tumor  for  an  emphysema  ;  the  result  being  of 
necessity  fatal.  In  cases  reported  by  Yerduc,  Petit,  Platner,  and 
Leudet,  the  aneurism  was  allowed  to  run  its  course  unchecked  by  efficient 
surgical  treatment,  and  in  every  instance  proved  fatal  by  the  sac  giving 
way',  and  secondary  hemorrhage  ensuing.  Sir  C.  Bell  records  a  case 
that  occurred  at  the  Newcastle  Infirmary',  in  which  the  pectoral  muscles 
as  well  as  the  artery  were  torn,  and  immediate  amputation  became  neces¬ 
sary.  In  four  cases  the  subclavian  arteiy  had  been  ligatured.  All  these 
happened  in  America ;  two  to  Gibson,  one  to  Blackman  of  Cincinnati, 


DISLOCATIONS  OF  THE  ELBOW-JOINT. 


415 


and  one  to  Warren.  Three  of  them  proved  fatal  by  secondary  hemor¬ 
rhage,  Warren’s  being  the  onl}'^  one  in  which  recovery  took  place. 

What  Treatment  should  be  adopted  in  this  distressing  accident  ?  If 
the  aneurism  be  left  to  itself,  or  be  treated  by  inefficient  means,  it  must 
necessarily  prove  fatal  b}"  its  rupture  or  sloughing  and  secondary  hemor¬ 
rhage.  The  ligature  of  the  subclavian  is  not  very  promising,  as  a  fatal 
result  occurred  in  three  out  of  the  four  cases  in  which  it  had  been  tried 
for  diffuse  aneurism.  Nekton’s  case  having  been  circumscribed.  In  these 
circumstances,  it  appears  to  me  that  it  would  be  wiser  to  apply  to  these 
cases  the  usual  principle  of  treatment  that  is  adopted  in  cases  of  diffused 
axillary  aneurism  from  other  causes ;  viz.,  to  compress  the  subclavian, 
lay  open  the  sac,  turn  out  coagula,  and  tie  the  torn  artery  at  the  seat  of 
injury. 

In  one  case,  the  dislocation  being  of  twenty  days’  standing,  and  the 
patient  a  female  26  years  old,  Froriep  states  that  reduction  was  followed 
by  sudden  and  extensive  tumefaction  of  the  axilla,  S3mcope,  and  death 
in  an  hour  and  a  half  A  post-mortem  examination  disclosed  laceration 
of  the  axillary  vein.  No  mention  is  made  of  any  internal  injury  to 
.account  for  death. 

Injuiy  to  the  axillary  nerves  during  reduction  leading  to  paral3’sis  of 
the  arm  has  also  been  described.  A  case  of  this  kind  is  mentioned  by 
Billroth  as  having  occurred  in  a  patient  under  his  care  at  Zurich.  The 
dislocation  was  of  nine  months’  standing,  and  had  been  attended  with 
partial  paral3'sis  of  the  arms  and  some  atroph3\  The  reduction  was 
followed  b3^  total  paralysis,  which  Billroth  attributes  to  laceration  of  the 
axillary  nerves  in  consequence  of  their  having  become  adherent  to  the 
bone. 

Besides  these  accidents,  other  evil  consequences  have  occasionall3’ 
followed  prolonged  attempts  at  reducing  old  dislocations  of  the  humerus, 
such  as  sudden  death  from  syncope.,  and  exhaustion.  Guerin’s  remark¬ 
able  case  of  avulsion  of  the  limb  at  the  elbow  in  a  woman  63  3’ears  of 
age,  in  an  attempt  to  restore  a  dislocated  humerus  three  months  after 
the  luxation  had  occurred,  is  an  instance  of  an  accident  that  is  as  3’et 
unique  in  the  records  of  surgery.  In  this  case  no  undue  amount  of  force 
seems  to  have  been  used,  but  the  tissues  of  the  limb  had  become  softened 
and  porous — partl3^  probabl3^  from  disuse,  partl3"  from  senile  changes. 

In  the  event  of  the  Surgeon  being  unsuccessful  in  his  attempts  at 
reduction,  he  must  endeaA’or,  by  means  of  frictions  and  passive  motion, 
to  restore,  as  far  as  practicable,  the  utility  of  the  limb.  In  some  of 
these  cases  of  old  reduced  dislocation,  I  have  succeeded  in  veiy  mate¬ 
rially  improving  its  condition  by  putting  the  patient  under  the’influence 
of  chloroform,  and  moving  the  limb  freel3^  to  and  fro  so  as  to  loosen, 
stretch,  and  break  up  the  adhesions  about  the  head  of  the  bone ;  and  it 
is  in  this  way  that  attempts  at  reduction,  even  though  unsuccessful  in 
replacing  the  head  of  the  bone,  are  often  of  great  use  in  improving  the 
mobility  of  the  limb. 

In  cases  of  old  standing,  where  symptoms  of  pressure  on  the  large 
vessels  and  nerves  are  present,  and  where  there  is  danger  of  their  being 
injured  in  the  attempt  at  reduction,  Billroth  recommends  excision  of  the 
head  of  the  bone.  This  has  been  done  successfully  by  Langenbeck  iu  a 
case  of  paral3"sis  from  pressure. 

Dislocations  of  the  Elbow  are  b3"  no  means  unfrequent  accidents ; 
and,  as  they  are  often  occasioned  by  direct  Auolence,  in  consequence  of 
Avhich  much  swelling  speedily  sets  in,  their  signs  are  frequently  obscured, 
and  the  diagnosis  is  rendered  proportionatel3’  difficult ;  more  especially 


416 


SPECIAL  DISLOCATIONS. 


when  the  dislocation  happens  to  he  complicated  with  fracture  of  the 
articular  ends  of  the  bones.  In  these  cases,  indeed,  it  is  only  b}'  a  correct 
acquaintance  with  the  normal  relations  of  the  osseous  points,  and  by  a 
comparison  between  those  of  opposite  sides,  that  the  Surgeon  can  detect 
the  true  nature  of  the  injury. 

The  Varieties  of  dislocation  of  the  elbow-joint  are  very  numerous, 
either  both  bones  of  the  forearm  or  only  one  being  implicated. 

1.  Both  Bones. — The  most  common  dislocation  is  that  In  which  both 
bones  are  thrown  Backwards.,  with  or  without  fracture  of  the  coronoid 
process.  This  injury  is  readily  recognized  by  the  projection  backwards 
of  the  olecranon,  canying  with  it  the  tendon  of  the  triceps.  The  articu¬ 
lar  end  of  the  humerus  also  can  be  felt  projecting  in  front  of  the  elbow. 
When  the  coronoid  process  is  not  broken  off,  it  is  fixed  against  the  pos¬ 
terior  surface  of  the  humerus,  the  forearm  being  immovably  placed  in 
its  new  position.  When  this  process  is  fractured,  there  is  great  mobility 
about  the  joint,  and  crepitation  ma^^  be  felt  as  the  arm  is  drawn  forwards. 

Dislocation  of  both  bones  Forivards  can  scarcely  occur  without  frac¬ 
ture  of  the  olecranon.  Rare  as  this  accident  must  be,  there  are  at  least 
five  cases  on  record  by  Colston,  Lana,  Delpech,  Canton,  and  Forbes  of 
Philadelphia,  in  which  the  bones  have  been  so  displaced  without  this 
j)rocess  being  broken.  In  this  injury  the  elongation  of  the  forearm,  the 
projection  of  the  condyles  of  the  humerus,  the  presence  of  the  sigmoid 
notch  in  front  of  the  arm  and  the  depression  of  the  posterior  surface  of 
this  bone,  render  the  diagnosis  sufficiently  easy.  In  one  case  at  Uni¬ 
versity  College  Hospital,  the  accident  occurred  by  the  patient,  a  man 
20  years  of  age,  slipping  on  the  pavement  and  falling  on  his  elbow.  In 
this  instance  the  elbow  was  much  bent ;  it  could  be  brought  to  a  right 
angle,  and  straightened  considerably.  The  forearm  was  three-quarters 
of  an  inch  longer  than  its  fellow.  The  condyles  of  the  humerus  were  on 
a  level  with  the  olecranon  ;  the  tendon  of  the  triceps  was  very  tight, 
and  the  sigmoid  notch  could  be  plainly  felt  on  the  forepart  of  the  arm. 
The  head  of  the  radius  could  also  be  felt  in  front  of  the  humerus. 
When  the  olecranon  is  broken  off,  there  is  elongation  of  the  forearm 
and  great  mobility,  but  the  detached  fragment  can  be  felt  behind  the 
humerus. 

The  Lateral  dislocation  of  the  bones  of  the  forearm  is  almost  inva¬ 
riably  incomplete ;  either  the  head  of  the  radius  hitching  against  the 
internal  cond3de  or  the  ulna  coming  into  contact  with  the  external  one. 
Complete  lateral  dislocation  of  the  bones  of  the  forearm  is  excessively 
rare :  the  only  instance  with  which  I  am  acquainted  is  a  luxation  out¬ 
wards,  reported  by  Relaton-,  of  which  he  has  given  a  woodcut. 

The  ulna  or  radius  alone  ma}-^  be  displaced ;  and  in  some  cases,  both 
bones  are  dislocated,  but  in  opposite  directions. 

2.  Ulna. — The  onl^"  dislocation  to  which  the  ulna  alone  is  subject  is 
that  in  a  direction  Backwards.  Although  this  displacement  ma}^  occur 
in  an  uncomplicated  form,  it  is  more  frequently"  associated  with  more 
or  less  dislocation  of  the  head  of  the  radius.  When  it  occurs,  it  may 
be  recognized  by"  the  projection  of  the  olecranon  backwards,  and  by  the 
head  of  the  radius  being  felt  in  its  normal  situation,  or  nearly  so,  during 
the  movements  of  pronation  and  supination.  In  some  extremely^  rare 
cases  the  coronoid  process  is  fractured  at  the  same  time,  causing  ready 
disappearance  and  recurrence  of  the  dislocation,  with  crepitus. 

3.  Radius. — The  radius  alone  may  be  dislocated /bricarcZs,  backwards., 
or  outwards.  The  dislocation  Forivards  is  certainly  the  most  common. 
In  the  many  instances  of  it  that  I  have  seen,  it  has  resulted  from  a  fall 


DISLOCATIOXS  OF  THE  ELBOW-JOIXT. 


417 


on  the  palm  of  the  hand,  which  the  lower  end  of  the  radius  is  driven 
backwards,  while  the  upper  end  is  tilted  forwards  with  the  whole  force  of 
the  leverage  of  the  bone,  and  in  this  way,  rupturing  the  annular  liga¬ 
ment,  is  thrown  against  the  external  cond^de.  The  signs  of  this  dis¬ 
placement  are  the  following.  The  forearm  is  slight^  flexed,  and  in  a 
mid  state  between  pronation  and  supination ;  any  attempt  at  completing 
the  letter  position  occasions  great  pain,  as  does  also  the  endeavor  to 
straighten  the  arm.  The  elbow  can  only  be  bent  at  an  obtuse  angle,  in 
consequence  of  the  head  of  the  radius  being  suddenly  brought  up  against 
the  lower  end  of  the  humerus,  against  which  it  strikes  with  a  sudden 
shock  (Figs.  173, 175).  On  rotating  the  radius  much  pain  is  experienced. 


Fig.  173. 


Dislocation  of  the  Radius  forwards:  Limit  of  Power  of  Bending  the  Arm. 

and  the  head  of  the  bone  can  be  felt  to  roll  on  the  forepart  of  the 
humerus,  the  external  cond3des  of  which  project  unnaturall3\  The  hand 
and  arm  can  be  fully  pronated,  but  cannot  be  supinated  more  than  half 


Fig.  174. 


Dislocation  of  the  Radius  forwards:  Deformity  of  Outer  Side  of  the  Arm  when  Extended. 


way.  The  whole  of  the  outer  side  of  the  arm  is  deformed,  being  carried 
somewhat  upwards  (Fig.  174).  The  rupture -of  the  annular  ligament  in 


Fig.  175. 


Position  of  the  Bones  in  an  old  Unreduced  Dislocation  of  the  Radius  forwards. 


this  dislocation  makes  it  very  difllcult  to  keep  the  head  of  the  radius 
properly’  fixed,  so  as  to  prevent  a  recurrence  of  the  displacement. 

YOL.  I. — 27 


418  ' 


SPECIAL  DISLOCATIONS. 


In  some  cases,  and  indeed  not  unfrequentlj",  there  is  incomplete  dislo¬ 
cation  of  the  radius  foricards^  arising  either  from  falls  upon  the  hand, 
or  from  violent  twists  of  the  forearm.  In  these  we  have  the  preceding 
signs,  though  less  marked.  The  most  characteristic  symptom,  however, 
is  the  patient’s  inability  to  flex  the  forearm  upon  the  arm.  This  he  can 
never  do  to  a  greater  extent  than  to  bring  the  elbow  to  a  right  angle 
(Fig.  ITS).  On  being  told  to  touch  the  tip  of  his  shoulder  with  his  fore¬ 
finger,  he  will  find  it  impossible  to  do  so. 

The  dislocation  of  the  radius  Backicards  is  extremely  rare ;  it  may 
always  be  recognized  bj^the  head  of  that  bone  being  felt  subcutaneously 
behind  the  external  condyle;  the  movements  of  the  elbow,  and  the  radius 
especially,  being  at  the  same  time  very  limited  and  painful. 

Dislocation  of  the  radius  Outwards  is  of  more  frequent  occurrence 
than  the  last  injury,  the  head  of  the  bone  being  thrown  on  the  outer  side 
of  the  external  condyle,  where  it  is  felt  under  the  skin,  rolling  as  the 
hand  is  moved.  The  natural  motions  of  the  joint  are  of  course  greatly 
interfered  with. 

The  radius  and  ulna  are  sometimes  displaced  in  Opposite  Directions^ 
the  ulna  being  thrown  backwards^  and  the  radius  forwards.  This  injury, 
of  which  I  have  seen  two  instances  at  the  hospital,  usually  results  from 
heav}’  falls  upon  the  hand,  with  a  wrench  of  the  limb  at  the  same  time, 
as  when  a  person  is  thrown  out  of  a  carriage,  or  lights  upon  his  hands, 
in  consequence  of  wdiich  the  bones  are  twisted  and  displaced  in  opjDOsite 
directions.  The  deformity  is  of  course  great,  but  is  readil}^  recognized 
by  the  combination  of  the  characters  of  the  two  forms  of  displacement, 
provided  an  examination  be  made  before  the  swelling  has  come  on,  which 
rapidly  sets  in. 

Complications. — Dislocations  of  the  elbow-joint  are  very  frequently 
complicated  with  fracture  of  one  or  other  condyle  of  the  humerus,  of  the 
olecranon,  and — as  we  have  already  seen  in  displacement  of  the  ulna,  and 
more  rarely — of  the  coronoid  process.  In  these  complicated  injuries  an 
exact  diagnosis  is  often  extremely  difficult,  owing  to  the  looseness  and 
mobility  of  the  x^arts,  and  to  the  great  tumefaction  that  accompanies 
accidents  of  this  description.  It  is  in  these  cases  that  a  good  knowledge 
of  the  relative  bearing  of  the  different  osseous  points,  aided  by  a  com- 
X^arative  examination  of  the  opposite  limb,  will  alone  enable  the  Surgeon 
to  effect  a  proper  diagnosis  of  the  nature  of  the  injuiy. 

The  mode  of  Reduction  in  dislocations  of  the  elbow-joint  varies  accord¬ 
ing  as  the  ulna  is  displaced  or  not.  When  the  ulna  is  dislocated,  in 
whatever  direction  it  mav  be  thrown,  and  whether  the  radius  be  dis- 
placed  at  the  same  time  or  not,  the  great  obstacle  to  reduction  is  the 
hitching  of  the  x^rocesses  of  the  bone  against  the  articular  end  of  the 
humerus.  If  either  the  olecranon  or  coronoid  process  be  fractured,  this 
entanglement  cannot  take  place,  and  the  joint  then  readily  slips  into  its 
position,  though  it  is  very  difficult  to  maintain  it  there.  The  reduction 
of  the  displaced  ulna,  when  uncomplicated  by  fracture,  maj'  always  be 
effected,  as  Sir  A.  Cooper  has  recommended,  by  bending  the  arm  over 
the  knee.  The  x^atient  being  seated  on  a  chair,  the  Surgeon  rests  one 
foot  upon  the  seat,  and,  x^lacing  the  knee  in  the  bend  of  the  injured 
elbow,  grasps  the  forearm  with  both  hands  (Fig.  116) ;  fixing  the  arm, 
he  presses  the  knee  firmly  against  the  inner  aspect  of  the  forearm,  so  as 
to  disengase  the  ulna  from  the  lower  end  of  the  humerus,  and  at  the  same 
time  he  bends  or  pushes  the  forearm  into  proper  position,  into  which, 
indeed,  it  has  a  tendency  to  return  by  the  action  of  its  own  muscles,  so 
soon  as  the  opposing  osseous  surfaces  are  separated. 


COMPOUND  DISLOCATIONS  OF  THE  ELBOW. JOINT.  419 

In  dislocations  of  the  radius,  this 
movement  across  the  knee  is  not  ne¬ 
cessary.  All  that  is  required  is  to 
fix  the  upper  arm,  and  then,  employing 
extension  from  the  wrist,  to  straighten 
the  arm  well ;  when,  by  bending  the 
elbow  at  right  angles,  the  head  of  the 
radius  maj^  be  pressed  into  a  proper 
position. 

After  reduction  has  been  eflfected, 
the  limb  should  be  firmly  put  up  in 
lateral  angular  splints,  the  hand  being 
kept  semi-prone.  If  the  radius  have 
been  displaced,  a  pad  should  be  ap¬ 
plied  over  its  head,  so  as  to  prevent  a 
return  of  the  displacement,  which  is 
very  apt  to  occur  when  the  orbicular 
ligament  is  torn.  In  the  case  of  dis¬ 
location  of  the  radius  forwards^  how¬ 
ever,  reduction  is  best  maintained  by 
placing  the  arm  in  the  extended  posi¬ 
tion,  and  applying  a  straight  splint, 
well  padded,  along  the  palmar  aspect 
of  the  limb.  The  inflammation  which 
usually  results  must  be  combated  by 
the  free  applications  of  leeches  and  of 
evaporating  lotions.  When  this  has  subsided,  passive  motion  may  be 
commenced,  and  frictions  and  douches  employed,  so  as  to  remove  the 
stiffness  that  is  apt  to  be  left  about  the  joint. 

In  those  cases  in  which  the  dislocation  is  complicated  with  fracture  of 
some  part  of  the  articular  ends,  and  in  which  the  diagnosis  of  the  precise 
nature  of  the  injury,  owing  to  the  swelling  or  other  causes,  has  not  been 
very  clearly  made  out,  the  joint  should  be  placed  in  as  good  a  position 
as  possible,  by  a  process  of  traction,  flexion,  and  moulding,  so  as  to  bring 
the  osseous  points  into  proper  bearing  with  one  another ;  the  angular 
splints  must  then  be  applied  and  local  antiphlogistic  treatment  employed. 
At  the  end  of  a  month  or  flve  weeks  passive  motion  may  be  commenced, 
lest  permanent  rigidity  come  on,  which  is  very  apt  to  supervene. 

Compound  Dislocations  of  the  Elbow  are  always  very  serious  injuries. 
In  tlieir  treatment,  the  Surgeon  will  usually  have  to  decide  between 
resection  of  the  articular  ends  of  the  displaced  bones  and  amputation  of 
the  arm.  He  will  be  guided  in  his  course  by  the  amount  of  mischief  done 
to  the  soft  parts.  If  these  be  simply  lacerated  over  the  posterior  aspect 
of  the  joint — the  dislocation,  when  compound,  being  almost  inv^ariably 
backwards — the  wound  may  be  enlarged,  and  the  articular  ends  removed. 
Should  the  soft  structures  be  extensively  contused  and  torn,  the  brachial 
artery  or  the  median  nerve  injured,  and  the  bones  fractured  as  well  as 
dislocated,  amputation  will  be  the  safer  course.  In  determining  on  the 
line  of  practice,  however,  the  Surgeon  will  be  guided  by  the  considera¬ 
tions  stated  at  p.  357,  in  reference  to  compound  fracture  of  this  joint. 

Old-standing  Dislocations  of  the  Elbow  are  reduced  with  much  diffi¬ 
culty  in  all  cases  in  which  the  ulna  is  completely  displaced  ;  this  is  owing 
rather  to  the  interlocking  of  the  irregular  articular  surfaces  and  to  the 
formation  of  adhesions  in  the  torn  capsule  and  around  the  displaced 
bones,  than  to  muscular  contraction.  The  tendon  of  the  triceps,  and 


Fig.  176. 


Dislocatioa  of  the  Ulna ;  Reduction. 


420 


SPECIAL  DISLOCATIONS. 


even  that  of  the  biceps,  have  been  divided  in  some  of  these  cases  of  old- 
standing  dislocation  of  the  elbow,  in  order  to  facilitate  reduction.  In 
those  instances  in  which  I  have  done  this  operation  or  seen  it  adopted, 
but  little,  if  any,  good  has  resulted  ;  and  I  have  known  troublesome 
sloughing  to  ensue.  As  a  general  rule,  I  believe  that  it  will  be  found 
extremely  difficult,  even  under  chloroform  and  with  the  aid  of  the  pulleys, 
to  reduce  an  ulna  that  has  been  completely  dislocated  for  more  than  a 
month.  When  the  ulna  is  only  partially  dislocated,  even  though  the 
radius  be  completely  displaced,  reduction  may  be  effected  without  much 
difficulty  at  a  very  much  later  period — it  is  said,  as  late  as  two  3’'ears 
after  the  accident;  but  here  the  difficulty  is  not  to  effect  but  to  maintain 
the  reduction  and  keep  the  bone  in  position,  as  it  has  a  constant  tendency 
to  slip  forwards  and  outwards.  Provided  a  dislocated  elbow  can  be  so 
far  reduced  as  to  allow  the  forearm  to  be  bent  at  a  right  angle,  an  useful 
arm  will  be  left. 

Dislocations  of  the  Wrist  are  of  rare  occurrence  ;  so  much  so,  that 
their  existence  has  been  denied  by  Dupuytren  and  other  modern  Sur¬ 
geons  of  great  experience.  Although  there  can  be  no  doubt  that  frac¬ 
tures  of  the  lower  end  of  the  radius,  more  especially  of  an  impacted  cha¬ 
racter,  have  often  been  mistaken  for  these  displacements,  j^et  there  can 
be  now  no  question  that  they  do  occasional!}' ,  though  rarely,  occur.  An}' 
doubt  that  may  formerly  have  existed  upon  this  point,  in  consequence 
of  the  want  of  pos^moWem  examinations,  has  been  in  recent  years  cleared 
up  by  the  dissections  of  cases  that  have  been  made  by  Marjolin  and  Yoil- 
lermier.  The  observations  of  these  Surgeons,  together  with  those  pre¬ 
viously  made  by  Sir  A.  Cooper,  tend  to  show  that  dislocation  of  the 
Hand  and  Carpus  from  the  radius  may  take  place  either  backwards  or 
forwards. 

These  accidents  are  occasioned  either  by  falls  on  the  palm,  or  by  the 
hand  being  forcibly  bent  forwards.  In  falls  on  the  palm,  the  hand  may 
be  thrown  forwards  under  the  bones  of  the  forearm,  lying  on  their  palmar 
aspect.  In  forcible  bending  of  the  hand  forwards,  there  may  be  displace¬ 
ment  of  it  and  the  carpus  backwards  on  the  dorsal  aspect  of  the  radius 
and  ulna. 

In  the  Dislocation  of  the  hand  and  Carpus  Backwards — the  Dorsal  dis¬ 
placement — there  will  be  shortening  of  the  length  of  the  limb  below  the 

elbow  with  a  large  dorsal  promi¬ 
nence  occasioned  by  the  carpus 
overlapping  the  lower  end  of  the 
radius,  which  bone  will  be  felt  and 
seen  as  a  projection  on  the  palmar 
side. 

In  the  other  variety  of  radio¬ 
carpal  dislocation,  the  Hand  and 
Carpus  are  thrown  Forwards 
under  the  radius  and  ulna  on 
their  Palmar  aspect.  This  dis¬ 
location  is  illustrated  in  the  ac¬ 
companying  figure  taken  from  a 
cast  sent  to  me  by  Cadge,  of  Nor¬ 
wich  (Fig.  177).  In  it  the  projection  of  the  styloid  process  of  the  ulna 
and  the  lower  end  of  the  radius  form  a  concave  line  on  the  dorsal  aspect, 
overlapping  the  carpus,  which  lies  on  the  palmar  side  of  the  radius. 

The  Diagnosis  of  these  injuries  has  to  be  made  from  sprains  of  the 
wrist,  from  simple  and  from  impacted  fractures  of  the  radius.  From 


Dislocation  of  the  Hand  and  Carpus  forwards. 


DISLOCATIONS  OF  SINGLE  BONES  OF  CARPUS.  421 


sprains  of  the  wrist,  the  great  and  prominent  deformity  will  at  once  ena¬ 
ble  the  Surgeon  to  distinguish  a  dislocation.  From  simple  fracture  of 
the  lower  end  of  the  radius,  the  peculiar  deformity,  and  the  absence  of 
crepitus,  will  afford  ready  means  of  diagnosis.  It  is  from  the  impacted 
fracture  of  the  lower  epiphysis  of  the  radius  that  it  is  most  difficult  to 
distinguish  a  dislocation.  In  the  dislocation,  however,  the  general  laxity 
of  the  wrist-joint,  the  greater  readiness  with  which  the  deformity  is 
removed,  the  peculiar  and  abrupt  swelling,  and  the  absence  of  obliquity 
of  the  hand  towards  the  radial  side,  will  enable  the  Surgeon  to  distinguish 
the  true  nature  of  the  injury. 

The  Treatment  of  these  cases  is  simple,  and  in  accordance  with  gene¬ 
ral  principles.  Reduction  which  is  readily  effected,  must  be  maintained 
by  the  application  of  antero-posterior  splints  of  sufficient  length  to  take 
in  the  hand. 

Compound  Dislocation  of  the  Wrist^  without  fracture  of  the  bones  of 
the  forearm,  is  a  rare  accident.  In  one  such  case  which  came  under  my 
care  at  the  Hospital,  in  consequence  of  injury  inflicted  on  the  arm  by 
machinery,  the  hand  was  thrown  forwards,  the  radius  projecting  back¬ 
wards,  and  t'he  soft  structures  on  the  palmar  aspect  of  the  joint  were  so 
extensively  torn  through  as  to  necessitate  amputation.  The  Treatment 
of  such  a  case  will  depend  on  the  amount  of  injury  done  to  the  soft  parts. 
If  these  be  not  very  extensively  injured,  an  attempt  nia3^be  made  to  save 
the  limb ;  but  if  they  be  widely  torn  through,  the  arteries  and  nerves 
lacerated,  and  the  tendons  perhaps  hanging  out,  amputation  will  be 
required;  this  occurred,  and  the  operation  was  performed,  in  the  case  to 
which  I  have  just  referred.  This  will  be  rendered  more  imperative  if  the 
bones  of  the  forearm  be  comminuted  as  well. 

Congenital  Dislocation  of  the  Wrist  may  take  place  either  forwards  or 
backwards.  The  limb  is  in  either  case  greatly  deformed.  The  bones 
are  shortened  and  altered  in  shape,  more  especiall}’^  the  lower  end  of  the 
radius.  The  muscles  are  also  shortened,  the  extensor  tendons  forming 
a  sharp  angle  as  they  pass  over  the  carpus. 

Dislocations  of  Single  Bones  of  the  Carpus  are  b}^  no  means 
frequent.  The  bone  that  is  most  commonly  displaced  is  the  Os  3Iagnum. 
This  accident  usually  happens  from  falls,  in  which  the  hand  is  violently 
bent  forwards,  in  consequence  of  which  this  bone  starts  out  from  its 
articulation,  projecting  as  a  round  hard  tumor  on  the  back  of  the  wrist 
opposite  to  the  metacarpal  bone  of  the  middle  finger.  It  may  be  readily 
reduced  b^r  being  pressed  upon  while  at  the  same  time  the  hand  is  ex¬ 
tended.  There  is,  however,  a  great  tendenc}''  for  this  bone  to  slip  out 
again,  leaving  considerable  weakness  of  the  joint;  so  much  so,  that  in 
two  cases  recorded  by  Sir  A.  Cooper,  the  patients  found  it  necessaiy  to 
wear  artificial  supports. 

The  Pisiform  Bone  is  occasionally  dislocated  upwards.  In  a  case 
under  my  care,  it  was  displaced  by  an  effort  to  lift  a  heavy  weight,  and 
drawn  up  the  arm  to  a  distance  of  nearly  an  inch  b}^  the  flexor  carpi 
ulnaris. 

A  case  some  time  ago  occurred  to  me,  at  the  Hospital,  in  which  the 
Semilunar  Bone  was  dislocated.  The  patient  had  fallen  from  a  height, 
injuring  his  spine,  and  doubling  his  right  hand  under  him.  On  examining 
the  wrist,  a  small  hard  tumor  was  felt  projecting  on  its  dorsal  aspect ; 
it  readily  disappeared  on  extending  the  hand  and  employing  firm  pres¬ 
sure,  but  started  up  again  so  soon  as  the  wrist  was  forcibly  fixed.  It 
was  evident  that  this  bone  belonged  to  the  first  row  of  the  carpus,  articu¬ 
lating  with  the  radius ;  and  from  its  size,  its  position  towards  the  radial 


422 


SPECIAL  DISLOCATIONS. 


side  of  the  carpus,  and  its  shape,  which  could  be  very  distinctly  made 
out  through  the  integuments,  there  could  be  little  doubt  that  it  was  the 
semilunar  bone.  Taaffe,  of  I3righton,  has  related  a  case  in  which  the 
semilunar  bone  was  dislocated  anteriorly,  so  that  it  projected  upwards 
and  forwards  between  the  radius  and  ulna. 

Dislocations  of  the  Metacarpal  Bones. — The  3Ietacarpal  Bones 
may  possibly,  though  very  rarely,  be  dislocated  from  the  carpus.  This 
accident  usually  happens  to  a  sibgle  metacarpal  bone,  which,  in  conse¬ 
quence  of  some  extreme  degree  of  violence,  is  forced  out  of  its  bed  and 
is  thrown  backwards  on  the  carpus.  Most  frequently  this  accident  is  the 
result  of  injury  and  shattering  of  the  hand  by  gun-barrel  or  powder-flask 
explosions ;  and  in  such  cases  the  metacarpal  bone  of  the  Thumb  is  the 
one  that  commonly  suffers,  the  dislocation  also  usually  being  compound, 
and  complicated  with  fracture  of  the  bones  and  extensive  palmar  lacera¬ 
tion.  Dislocation  of  the  metacarpal  bone  of  the  thumb,  however,  is  rare, 
though  the  articulation  between  this  bone  and  the  trapezium  appears  at 
first  not  to  be  of  a  character  to  resist  much  external  violence.  This  is 
probably  owing  in  a  great  measure  to  the  powerful  muscles  by  which  the 
bone  is  supported  in  all  cases  in  which  the  force  is  applied  upon  its  palmar 
aspect,  as  it  most  frequently  is,  as  well  as  to  the  little  leverage  offered 
by  so  short  a  bone.  Luxation,  hov^ever,  of  the  metacarpal  bones  of  the 
thumb  has  been  observed  to  take  forwards  as  well  as  backivards, 
the  latter  being  the  most  common.  The  Reduction  is  in  general  easy, 
extension  being  made  from  the  thumb  by  means  of  a  piece  of  tape  applied 
round  the  first  phalanx. 

Next  to  the  metacarpal  bone  of  the  thumb,  those  of  the  Index  and 
3Iiddle  Fingers  are  most  liable  to  dislocation  backwards;  sometimes 
complete,  at  others  incomplete. 

I  am  not  acquainted  with  any  case  on  record  in  which  all  the  meta¬ 
carpal  bones  have  been  dislocated  from  the  carpus.  The  annexed 

engraving  (Fig.  178)  is  from  a  cast  in  University 
College  Museum,  taken  from  a  patient  in  the 
Hospital,  in  whom  I  believe  that  this  accident 
must  have  occurred  ;  the  hand  being  thrown  for¬ 
wards  and  shortened,  and  the  carpal  bones  form¬ 
ing  a  rounded  and  convex  prominence  on  the 
dorsum  of  the  metacarpus.  The  convex  appear¬ 
ance  of  this  corresponds  with  the  outline  of  the 
carpal  bones,  and  differs  so  very  remarkably 
from  the  concave  aspect  of  the  lower  end  of  the 
radius  and  ulna,  as  seen  in  the  radio-carpal  dis¬ 
location  (Fig.  177),  that  I  think  there  can  be  little 
doubt  as  to  the  nature  of  the  injury  sustained  by 
the  patient. 

The  Treatment  of  such  cases  will  be  the  same 
as  that  for  ordinary  dislocations  of  the  carpal 
bones ;  splints  of  sufficient  length  to  take  in  the 
hand  being  applied,  after  reduction,  in  order  to 
maintain  the  parts  in  position. 

Dislocations  of  the  Metacarpo-Phalan- 
geal  Articulations  are  bj’-  no  means  of  com¬ 
mon  occurrence.  They  are  usually  produced  by 
falls  on  the  hand,  and  are  met  with  at  all  ages ; 
most  commonly  in  the  young  adult,  but  some¬ 
times  at  an  earlier  age.  I  have  seen  this  accident  in  a  child  four  years 


Fig.  178. 


Dislocation  of  the  Metacar¬ 
pus.  Forwax'ds,  from  the  Car¬ 
pus. 


DISLOCATIONS  OF  THE  THUMB. 


423 


old.  Most  frequently  the  Proximal  Phalanx  of  the  Thumb  is  the  bone 
that  is  dislocated,  being  thrown  backward  on  the  metacarpal  bone  (Fig. 
1T9)  in  such  a  way  that  the  articular  surface  of  the  phalanx  rests  upon 
the  back  of  the  metacarpal  bone  immediately  below 
its  head.  The  signs  of  the  accident  are  sufficiently 
evident.  In  the  normal  state  of  the  hand,  the 
metacarpo-phalangeal  articulation  of  the  thumb  is 
convex  backwards:  in  this  dislocation,  it  becomes 
convex  towards  the  palmar  aspect  and  angularly 
concave  behind.  The  head  of  the  metacarpal  bone 
can  be  felt  and  seen  projecting  on  the  palmar  aspect 
of  the  thumb.  The  proximal  phalanx  stands  up  as 
it  w'ere  upon  the  back  of  this  bone,  but  the  articular 
surface  of  the  phalanx  cannot  be  felt,  owing  to  its 
being  in  contact  with  the  posterior  part  of  the 
metacarpal  bone  just  above  its  neck.  The  phalan¬ 
geal  articulation  is  always  semi-flexed.  This  dislo¬ 
cation  of  the  proximal  phalanx  of  the  thumb  has, 
owing  to  the  difficulty  of  its  reduction,  attracted 
more  attention  from  Surgeons  than  it  would  at 
first  appear  to  deserve.  So  great  has  this  diffi¬ 
culty  been  in  some  cases,  as  to  render  the  dislocation  irreducible,  not¬ 
withstanding  the  employment  of  as  much  force  as  it  was  safe  to  use, 
and  that  most  skilfully  directed,  or  to  compel  the  Surgeon  to  have 
recourse  to  operative  interference  in  order  to  replace  the  head  of  the 
bone.  The  obstacle  to  the  ready  reduction  of  this  small  bone  has  been 
attributed  to  different  causes.  Thus,  Hey  supposed  that  it  was  owing  to 
the  constriction  of  the  neck  of  the  bone  between  the  lateral  ligaments  of 
the  joint.  Dupuytren  entertained  a  very  similar  opinion,  looking  upon 
the  malposition  of  these  ligaments  as  the  principal  source  of  difficulty. 
The  folding  in  of  the  anterior  ligament  of  the  joint,  and  the  interposition 
of  a  sesamoid  bone  between  the  articulatino;  surfaces,  have  also  been 
looked  upon  as  giving  rise  to  this  peculiar  difficulty  in  reduction.  The 
more  probable  explanation,  however,  appears  to  be,  that  the  narrow 
neck  of  the  metacarpal  bone  becomes  locked  between  or  constricted  by 
two  terminal  attachments  of  the  short  flexor  of  the  thumb,  which  must 
be  carried  back  over  its  broader  head,  together  with  the  displaced 
phalanx;  the  head  of  the  metacarpal  bone  being  grasped  between  these 
tendons  and  the  torn  capsule  of  the  joint,  like  a  stud  between  the  sides 
of  a  button-hole.  The  observations  of  Yidal,  Malgaigne  and  Ballingall 
point  to  this  as  the  cause  of  the  great  difficulty  in  reduction  that  is 
often  met  with. 

Reduction. — Although,  as  has  been  said,  great  difficulty  in  reduction 
is  often  met  with,  it  would  be  a  great  error  to  suppose  that  it  always 
exists.  On  the  contrary,  very  many  of  these  dislocations  are,  under 
chloroform,  most  readily  reduced  by  simple  traction  and  manipulation. 
Should  any  difficulty  be  experienced,  the  following  plan  will  usually 
answer.  The  hand  and  metacarpal  bone  being  fixed  by  an  assistant, 
the  Surgeon  bends  back  the  thumb,  so  as  to  bring  the  phalanx  to  a 
right  angle  wdtli  the  metacarpal  bone  on  which  it  is  displaced.  He  now 
employs  traction  in  the  axis  of  the  displaced  portion  of  the  thumb, 
keeping  the  metacarpal  bone  well  pressed  down  into  the  palm.  Having 
thus  unlocked  the  phalangeal  articular  surface  from  the  back  of  that 
bone,  he  draws  it  well  forwards,  and,  when  it  is  opposite  the  head  of  the 
metacaiq^al  bone,  bends  it  down  into  the  palm.  In  this  way  I  have 


Fig.  179. 


Dislocation  "backwards  of 
the  Proix'iinal  Phalanx  of 
the  Thumb. 


424: 


SPECIAL  DISLOCATIONS. 


reduced  a  dislocation  of  the  phalanx  backwards  between  five  and  six 
weeks  after  its  occurrence.  Simple  traction  in  the  straight  direction, 
however  forcible,  and  even  when  aided  by  the  pulleys,  will  do  little  if 
any  good  in  the  reduction  of  this  dislocation,  as  the  only  effect  is  to 
draw  the  slit  in  the  capsule  and  the  two  heads  of  the  short  fiexor  more 
tightly  than  ever  round  the  neck  of  the  bone.  Yery  severe  extension 
has  been  employed  without  any  effect;  and  there  is  the  tradition  in  the 
surgical  profession  in  London  of  a  thumb  having  been  dragged  off*  in 
the  attempt  to  reduce  this  dislocation  by  pulleys.  If  the  Surgeon  fail 
in  reducing  the  dislocated  phalanx  by  manipulation  under  chloroform, 
as  above  described,  or  b}^-  traction,  what  is  to  be  done?  In  these  cir¬ 
cumstances,  the  dislocation  should  not  be  left  without  a  further  effort  to 
replace  the  bone ;  and  this  may  usually  be  readil}’’  enough  done  by  the 
subcutaneous  section  of  the  resisting  structures.  The  Surgeon  must 
bear  in  mind  that  the  obstacle  to  reduction  is  purely  mechanical ;  that 
muscular  contraction  has  nothing  to  do  with  it ;  and  that  it  is  quite  as 
great  when  the  patient  is  anaesthetized  as  when  he  is  not.  He  must 
therefore  enlarge  the  slit  in  the  capsule,  and  divide  the  tense  bands 
formed  on  each  side  by  the  tendinous  attachments  of  the  short  flexor. 
This  operation  is  best  done  by  passing  a  tenotome  through  the  skin  in 
front  of  the  joint,  and  cutting  first  on  one  side,  then  on  the  other.  The 
chief  resistance  will  be  found  on  the  ulnar  side  of  the  thumb,  where  the 
tendinous  insertion  of  the  adductor  pollicis  is  probably  divided  at  the 
same  time  as  that  of  the  short  flexor  of  the  thumb.  After  these  struc¬ 
tures  have  been  cut  through,  the  phalanx  can  be  replaced,  and  the 
thumb  should  be  put  up  securely  between  splints. 

When  reduction  has  been  effected,  care  must  be  taken  to  prevent  the 
displacement  from  recurring.  This  is  best  done  by  keeping  the  thumb 
bent  into  the  palm,  and  retaining  it  there  by  means  of  a  gutta-percha 
cap  moulded  over  it  and  bandaged  down.  If  the  dislocation  be  left  un¬ 
reduced,  the  thumb  will  to  a  great  extent  become  useful,  but  necessarily 
shortened,  deformed,  and  incapable  of  much  flexion. 

In  Compound  Dislocation  of  this  joint,  the  bone  may  usually  readily 
be  replaced  ;  should  there  be  any  difficulty  in  retaining  the  bone  in  posi¬ 
tion,  its  head  must  be  removed,  the  dislocation  being  then  reduced  with 
great  readiness,  and  the  wound  treated  in  a  simple  manner. 

Dislocations  between  the  Phalanges  rarely  occur.  These  dis¬ 
locations  are  partial  or  incomplete,  and  usually  consist  of  a  twist  of 
the  second  upon  the  proximal  phalanx.  I  do  not  think  that  simple 

dislocation  of  the  ungual  phalanx  from  the  second  is 
possible.  Partial  dislocation  of  the  middle  phalanx, 
which  is  a  very  common  accident,  is  readily  recognized 
by  the  deformity  it  entails  (Fig.  180),  and  is  easily 
reduced  by  pressure  and  traction  in  proper  directions. 
A  very  convenient  mode  of  applying  traction  is  by 
means  of  the  toy  called  an  “  Indian  puzzle,”  which 
grasps  the  finger  more  tightly  the  more  it  is  pulled 
upon.  The  finger  will  continue  to  be  stiff  and  com¬ 
paratively  useless  for  some  length  of  time.  The  joint 
being  swollen  and  tender,  the  patient  can  generally 
bend  it,  but  cannot  extend  it  fully  or  bear  any  traction 
upon  it.  This  condition  is  especially  apt  to  be  trou¬ 
blesome  and  chronic  if  the  patient  be  gouty,  or  if  his 
the  Middle  Phalanx  of  general  health  be  otherwise  deranged,  and  requires 
the  Middle  Finger.  fcst  and  local  counter-iiTitation,  with  an  anti-gouty 


Fig.  180. 


DISLOCATIONS  OF  THE  PELVIS  AND  FEMUE.  425 

treatment,  for  its  remedy.  In  Compound  Dislocation  of  the  phalanges, 
the  bone  should  be  replaced,  the  finger  supported  by  a  gutta-percha 
splint,  and  the  wound  dressed  lightly.  In  some  cases  it  is  necessary 
to  remove  the  projecting  end  of  bone  before  this  can  conveniently  be 
done :  ankylosis  then  results,  a  sufficiently  useful  finger  being  left. 

Dislocations  of  the  Pelvis. — It  often  happens  that,  in  consequence 
of  severe  blows  upon  or  compression  of  the  pelvis,  the  Symphysis  of  the 
Pubic  Bones^  or  more  frequentl}^  the  Sacro-iliac  Articulation^  is  dis¬ 
placed.  Here  the  nature  of  the  injury  is  indicated  by  the  deformity 
that  results ;  and  the  same  treatment  is  required  as  in  fracture  of  the 
pelvis,  with  which  these  accidents  are  commonly  associated. 

The  Coccyx  is  sometimes  violently  bent,  and  almost  dislocated  for¬ 
wards  by  falls;  or  it  maybe  forcibly  bent  backwards  during  violent 
parturient  efforts.  These  accidents  may  be  remedied  by  manipulation 
tlirough  the  rectum  ;  but  are  apt  to  be  followed  by  that  painful  neuralgic 
affection  Coccydynia^  described  at  p.  365. 

Dislocations  of  the  Femur. — Notwithstanding  the  great  depth  of 
the  acetabulum,  the  complete  manner  in  which  the  head  of  the  thigh¬ 
bone  is  received  into  its  cavity,  the  firmness  of  the  capsular  ligament, 
and  the  great  strength  of  the  capsular  muscles  that  surround  and  sup¬ 
port  the  joint,  dislocations  of  the  hip  are  more  frequently  met  with  than 
those  of  many  other  joints  that  appear  less  perfectl}^  supported.  This 
is  doubtless  in  a  great  measure  owing  to  the  action,  on  the  head  of  the 
femur,  of  the  great  length  of  leverage  of  the  thigh-bone  itself  when 
external  violence  is  applied  to  the  knee,  and  of  the  whole  of  the  lower 
extremit}^  when  the  violence  is  applied  to  the  foot. 

The  different  forms  of  dislocation  of  the  femur  were  described  with 
great  clearness  and  precision  by  Sir  A.  Cooper,  who  showed  that  its  head 
is  most  commonly  thrown  upwards  and  somewhat  backwards^  so  as  to 
lodge  on  the  slightly  concave  surface  between  the  acetabulum  and  the 
crista  ilii,  resting  on  the  gluteus  minimus,  and  having  the  trochanter 
turned  forwards  (Fig.  181);  or  it  maybe  thrown  downwards  into  the 
foramen  ovale,  lying  upon  the  obturator  externus  muscle  (Fig.  183)  ;  or 
forwards  and  upwards  upon  the  horizontal  branch  of  the  pubic  bone 
under  the  psoas  and  iliac  muscles,  to  the  outer  side  of  the  femoral  ves¬ 
sels  (Fig.  184);  the  head  of  the  bone  may  also  be  thrown  backioards 
into  the  sacro-sciatic  notch,  resting  upon  the  pyriformis  muscle  (Fig. 
182).  These  are  the  four  forms  of  the  dislocation  of  the  hip  stated  by 
Sir  A.  Cooper  to  be  the  most  usual,  and  this  statement  has  been  fully 
confirmed  by  the  accumulated  experience  of  more  modern  Surgeons. 
Besides  these,  however,  may  be  added,  as  not  very  unfrequent,  that  form  in 
which  the  bone  is  thrown  backwards  and  somewhat  doiunwards  behind  the 
tuberosity  of  the  ischium.  In  addition  to  these,  other  less  common 
forms  of  dislocation  have  been  noticed;  for  instance,  one  in  which  the 
head  of  the  bone  lies  between  the  anterior  superior  and  the  anterior 
inferior  spinous  processes  of  the  ilium,  or  that  in  which  it  has  been 
thrown  upon  the  spine  of  the  ischium. 

The  extent  of  mischief  done  in  the  soft  parts  around  the  joint  varies 
in  different  dislocations.  In  all,  the  capsular  ligament  is  torn  in  a  greater 
or  less  extent  in  the  direction  of  the  displacement.  The  extent  and 
exact  situation  of  the  laceration  of  the  capsular  ligament  are  matters  of 
great  importance,  as  on  a  correct  appreciation  of  them  depends  in  a 
great  measure  the  facility  or  difficulty  in  reduction,  and  the  means  to  be 
employed  in  effecting  it.  The  ligamentum  teres  is  ruptured  in  most 
cases,  but  not  necessarily  in  all;  Dupuytren  and  Sedillot  both  mention 


426 


SPECIAL  DISLOCATIONS. 


cases  of  dislocation  on  the  dorsum  ilii  in  which  this  ligament  escaped 
without  rupture.  In  the  dislocation  on  the  dorsum  ilii,  Sir  A.  Cooper 
found  the  gemelli,  obturators,  and  quadratus  completely  torn  across, 
and  the  pectineus  slightly  torn.  In  the  dislocation  into  the  sciatic  notch, 

Fig.  181.  Fig.  182.  Fig.  183.  Fig.  184. 


DISLOCATIONS  OF  THE  HEAD  OF  THE  THIGH-BONE,  ACCORDING  TO  ASTLET  COOPER’S  CLASSIFICATION. 

Fig.  181. — Upwards  and  Fig.  182. — Back-  Fig  183. — Downwards  Fig.  184 — Forwards 

somewhat  Backwards,  on  wards  into  Sciatic  into  Foramen  Ovale.  and  Upwards  on  the 

Dorsum  Ilii.  Notck.  Pubic  Bone. 


Billard  d’Angers  found  the  gluteus  maximus  and  medius  torn,  and  the 
gemelli  ruptured.  Syme  found  the  gluteus  maximus  extensively  torn, 
with  the  head  of  the  bone  imbedded  in  it ;  the  gluteus  minimus,  the 
P3n’iformis,  and  the  gemellus  superior  lacerated  ;  and  the  head  of  the 
femur  Ijdng  upon  the  gemelli  and  the  great  sciatic  nerve.  In  the  dis¬ 
placement  on  the  obturator  foramen,  the  pectineus  and  adductor  brevis 
are  torn.  In  the  dislocation  on  the  obturator  foramen,  the  pectineus 
and  adductor  brevis  are  torn.  In  the  dislocation  on  the  pubic  bone,  the 
extent  of  injury'  is  more  uncertain.  In  one  case  related  by  Sir  A.  Cooper, 
Poupart’s  ligament  was  torn  up,  and  in  another  the  pectineus  and  adduc¬ 
tors  were  torn  ;  but  whether  this  was  done  by  the  dislocation  or  by  the 
direct  injuiy  that  occasioned  it,  is  uncertain. 

The  importance  of  the  ilio-femoral  ligament  in  the  mechanism  of  dis- 


DISLOCATIONS  OF  THE  FEMUR. 


427 


location  of  the  hip-joint,  has  been  fully  recognized  by  various  Surgeons. 
Gunn  of  Chicago,  Busch,  Yon  Pitha,  and,  more  recently  and  fully,  Bige¬ 
low,  have  insisted  on  an  exact  knowledge  of  this  important  ligament  as 
constituting  the  basis  of  a  correct  acquaintance  with  the  mechanism,  not 
only  of  the  various  forms  of  dislocation  of  the  hip,  but  also  of  the  proper 
mode  to  be  adopted  for  their  reduction.  Bigelow,  to  whom  especially 
we  are  indebted  for  a  most  lucid  exposition  of  the  subject,  gives  this 
structure,  from  its  shape,  the  name  of  the  he  believes 

that,  when  its  branches  are  unbroken,  one  or  other  of  the  four  regular 
dislocations  of  the  hip  will  occur:  the  particular  one  depending  upon 
the  relative  positions  of  the  head  of  the  femur  and  the  ilio-femoral  liga¬ 
ment.  In  no  case,  however,  do  anj^^  of  the  muscles,  except  perhaps  the 
obturator  internus,  exercise  any  influence  on  the  displacement.  When 
the  Y'hgament  is  ruptured,  an  irregular  dislocation,  the  signs  of  which 
may  be  uncertain,  will  occur.  The  strength  of  this  ligament  is  always 
great,  although  it  varies  much.  Bigelow  has  found  that  its  breaking 
power  in  the  dead  body  ranges  from  250  to  750  pounds. 

The  next  structure  of  most  importance,  as  has  been  pointed  out  by 
Bigelow,  is  the  obturator  internus  muscle.  He  has  shown  that  its  mus¬ 
cular  body  is  usually  intermixed  with  tendinous  structure.  In  conse¬ 
quence  of  this  arrangement,  it  acquires  great  strength  when  contracted, 
and,  indeed,  becomes  practically  an  accessory  ligament. 

Bigelow  classifies  dislocations  of  the  head  of  the  thigh-bone  into  Reg- 
ular  Dislocations.,  in  which  one  or  both  branches  of  the  Y  -ligament 
remains  unbroken  ;  and  Jrrc^w/ar,  in  which  the  is  wholly 

ruptured.  The  regular  dislocations  in  which  both  branches  remain 
entire,  are:  1,  Dorsal;  2,  Dorsal  below  the  tendon  (ischiatic  of  Cooper); 

3,  Thyroid  and  downward;  a,  obliquely  inward  on  the  thyroid  foramen; 
6,  obliquely  inward  as  far  as  the  perineum  ;  c,  vertically  downward 
beneath  the  acetabulum;  c?,  obliquely  outward  as  far  as  the  tuberosity; 

4,  Pubic  and  Subspinous;  5,  Anterior  oblique.  Those  in  which  the  ex¬ 
ternal  branch  is  broken  are:  6,  Supraspinous;  and  7,  Everted  Dorsal. 

With  regard  to  the  relative  frequency  of  the  various  forms  of  disloca¬ 
tion  of  the  hip.  Sir  A.  Cooper  says  that  of  20  cases  of  dislocation  of  the 
hip,  12  will  be  on  the  dorsum  ilii,  5  on  the  sciatic  notch,  2  on  the  obtu¬ 
rator  foramen,  and  one  on  the  pubic  bone.  Hamilton  states  that,  exclu¬ 
ding  anomalous  cases,  of  104  cases  of  dislocation  of  the  hip,  which 
he  has  collected,  55  were  on  the  dorsum  ilii,  28  into  the  sciatic  notch,  13 
into  the  obturator  foramen,  and  8  upon  the  pubic  bone. 

Dislocation  of  the  hip-joint  chiefly  occurs  in  young  or  middle-aged 
adults.  In  veiy  old  people,  fracture  of  the  neck  of  the  femur  will  com¬ 
monly  be  produced  by  the  same  violence  that  would  have  displaced  the 
head  of  the  bone  at  an  earlier  age.  In  children  dislocation  is  rare,  as 
the  shaft  will  generally  give  way.  Yet  it  does  happen  even  at  a  very 
early  age.  Two  cases  have  occurred  in  my  practice  at  the  Hospital.  In 
one  the  bone  was  dislocated  on  the  pubic,  in  a  child  a  year  and  a  half 
old;  in  the  other  one  the  dorsum  ilii  in  a  boy  of  six. 

For  convenience  of  description  and  with  a  view  to  practical  utility, 
we  may  arrange  dislocations  of  the  hip-joint  in  three  principle  varieties. 

I.  Dislocations  Upwards  and  Backwards. — The  most  common  dislo¬ 
cation  is  that  in  which  the  head  of  the  bone  is  thrown  upwards  and 
backwards  upon  the  dorsum  of  the  ilium,  or  rather  upon  that  portion 
of  the  bone  which  extends  between  the  acetabulum  and  the  sacrosciatic 
notch  (Fig.  181).  This  displacement  differs  so  slightly  in  its  pathology 
and  treatment  from  the  dislocation  into  the  sciatic  notch  (Fig.  182), 


428 


SPECIAL  DISLOCATIONS. 


described  as  a  distinct  variety  of  the  injury  by  Sir  A.  Cooper,  that 
I  think  it  is  more  consistent  with  the  true  nature  of  these  accidents  to 
look  upon  them  as  essential!}’  the  same ;  the  displacement  in  both  cases 
being  upwards  and  backwards,  but  in  different  instances  partaking 
more  of  one  or  other  direction.  This  dislocation  may  therefore  be  de¬ 
scribed  as  the  Ilio-sciatiG ;  it  corresponds  with  Bigelow’s  first  and  sec¬ 
ond  classes  of  regular  dislocation. 

2.  Dislocation  Doionwards. — Xext  in  order  of  frequency  to  the  ilio- 
sciatic  dislocation  is  the  Thyroid^  in  which  the  head  of  the  bone  is 
thrown  downwards  on  the  obturator  foramen.  The  downward  disloca¬ 
tions  include  also  those  on  the  perinseum  and  beneath  the  acetabulum. 

3.  Dislocation  Upwards. — In  the  Puhic  variety,  the  head  of  the  bone 
is  thrown  upward  on  the  pubic  bone.  In  a  more  rare  variety  of  upward 
dislocation,  it  may  lie  below  the  anterior  inferior  spine  of  the  ilium. 

Thus  it  will  be  seen  that,  in  whatever  direction  the  displacement  occurs, 
the  head  of  the  bone  has  a  tendency  to  sink  into  some  cavity  or  depres¬ 
sion,  or  to  lie  upon  one  of  the  osseous  surfaces  in  the  neighborhood  of 
the  acetabulum.  It  is  also  probable  that  the  hip  can  be  partially  dislo¬ 
cated. 

In  the  Reduction  of  dislocation  of  the  hip-joint,  two  methods  may  be 
employed.  The  first,  or  the  old  method,  consists  in  making  extension 
by  means  of  forcible  traction  by  pulleys  or  otherwise  in  the  direction  of 
the  axis  of  the  displacement  of  the  limb,  and  overcoming,  by  main  force, 
any  obstacle  arising  from  muscular  contraction  or  ligamentous  resist¬ 
ance.  The  other,  or  modern  method,  consists  in  the  employment  of 
manipulation by  which  is  meant  the  avoidance  of  all  force,  the  relaxa¬ 
tion  of  the  muscular  structures  by  flexion,  and  the  disentanglement  of  the 
head  of  the  bone  from  any  ligamentous  obstacle  by  impressing  on  it 
various  rotatory  movements,  each  adapted  to  the  particular  case. 
Originally  advocated  by  Xathan  Smith  in  1831,  extended  by  Reid  of 
Rochester  (XJ.  S.  A.)  in  1851,  this  method  has  now  in  America,  and  very 
commonly  in  this  country,  superseded  the  forcible  extension  of  Sir  A. 
Cooper  and  the  older  Surgeons  in  the  reduction  of  all  recent  disloca¬ 
tions  of  the  hip.  In  those  of  old  standing.,  extension  by  means  of  the 
pulley  is  still  required,  as  by  manipulation  sufficient  force  cannot  be 
exerted  to  overcome  those  secondary  causes  of  resistance  that  become 
developed  in  such  cases.  There  is  a  third  method — that  by  angular  ex¬ 
tension.,  invented  by  Ponteau;  but,  as  this  is  less  effective  than  either  of 
the  others,  and  never,  I  believe,  now  emifioyed,  its  consideration  need 
not  detain  us. 

I  shall  describe  each  method  of  reduction  in  connection  with  each  of 
the  principal  forms  of  dislocation  of  the  hip. 

1.  Dislocation  Upwards  and  Backwards  or  Ilio-sciatic.  If  the  head 
of  the  bone  rest  upon  the  dorsum  of  the  ilium  (Fig.  181),  the  hip  will  be 
found  to  be  a  good  deal  distorted,  the  gluteal  region  being  somewhat 
prominent,  and  the  upper  part  of  the  thigh  enlarged,  in  consequence  of 
the  approximation  of  the  muscular  attachments,  so  as  to  give  an  appear¬ 
ance  of  widening  to  the  hip.  The  head  of  the  bone  can  be  felt  in  its  new 
situation,  more  especially  on  rotating  the  limb ;  the  trochanter  is  less 
prominent  than  natural,  usually  lying  close  against  the  brim  of  the 
acetabulum,  and  being  turned  forwards;  there  is  marked  shortening, 
varying  from  one  to  two  inches  in  some  cases,  perhaps  even  as  much  as 
three  inches.  The  amount  of  shortening  will  necessarily  depend  upon 
the  distance  to  which  the  head  of  the  bone  is  thrown  upicards  on  the 
dorsum.  The  position  of  the  limb  is  remarkable,  being  distinctly  rotated 


ILIO-SCIATIC  DISLOCATION. 


429 


Fig.  185. 


inwards,  with  the  thigh  slightly  bent  upon  the  abdomen,  and  the  leg 
upon  the  thigh,  so  that  the  knee  is  semi-flexed,  and  raised  from  the 
surface  on  which  the  patient  is  lying.  The  foot  is  inverted,  so  that  the 
ball  of  the  great  toe  rests  on  the  instep  or  against  the  ankle  of  the  sound 
limb  ;  and  the  heel  is  somewhat  raised.  The  axis  of  the  dislocated  thigh 
is  directed  across  the  lower  third  of  the  sound  thigh.  The  movements  of 
the  joint  are  greatly  impaired ;  abduction  and  eversion  are  not  practi¬ 
cable;  but  inversion,  adduction,  and  some  flexion  upon  the  abdomen, 
can  be  practised.  When  the  patient  is  lying  flat,  wdth  the  knee  slightly 
raised  and  advanced,  the  lumbar  spine  is  on  its  proper  level ;  but  if  an 
attempt  be  made  to  straighten  the  knee,  so  that  the  limb  lies  flat,  the 
lumbar  spine  will  arch  forwards. 

When  the  head  of  the  bone  slips  a  little  further  back  so  as  to  become 
lodged  in  the  sciatic  notch^  we  have  the  dislocation  “backwards”  of  Sir 
A.  Cooper;  or,  as  Bigelow  calls  it,  “dorsal  below  the 
tendon,”  because  the  head  of  the  bone  lies  below  the 
tendon  of  the  obturator  internus  muscle  (Fig.  182).  In 
this  the  same  symptoms  exist,  though  to  a  less  degree  ; 
hence  the  diagnosis  is  proportionately  diflScult.  There 
is  much  less  deformity  about  the  hip  in  this  variety  of 
the  displacement,  owing  to  the  head  of  the  bone  sink¬ 
ing  into  the  hollow  of  the  notch,  and  thus  presenting 
the  trochanter  nearly  in  its  usual  position  at  right 
angles  with  the  ilium,  though  somewhat  behind  and  a 
little  above  its  normal  situation.  In  consequence  of 
the  head  of  the  bone  being  received  in  a  depression, 
the  axis  of  the  limb  is  not  altered  to  the  same  extent 
as  when  it  is  throwm  upon  the  plane  surface  of  the 
dorsum  ilii ;  hence  the  inversion  of  the  knee  and  foot, 
though  existing,  is  usually  not  so  strongly  marked. 

Bigelow,  however,  says  that  the  inversion  is  greater 
in  dislocation  “below  the  tendon”  (Fig.  185).  As 
the  sciatic  notch  is  but  a  little  above  the  level  of  the 
acetabulum,  the  shortening  of  the  limb  is  inconsider¬ 
able,  not  exceeding  half  an  inch  or  an  inch  at  most. 

The  axis  of  the  limb  also  is  directed  across  the  sound 
knee.  Thus  the  signs  of  these  two  forms  of  dislocation 
are  nearly  identical  in  character,  though  varying  in  degree  ;  the  principal 
difference  being  that,  when  the  head  of  the  bone  rests  in  the  sciatic 
notch,  the  axis  of  the  femur  is  directed  to  the  opposite  knee,  whereas, 
when  the  head  of  the  bone  is  lodged  on  the  dorsum  ilii,  the  axis  of  the 
limb  is  directed  across  the  lower  part  of  the  sound  thigh. 

Causes. — The  dislocation  upwards  and  backwards  is  that  which  is  most 
frequently  met  with  in  the  hip.  It  is  occasioned  by  violence  acting  upon 
the  limb  whilst  adducted,  with  the  body  bent  forwards  upon  the  thigh, 
or  the  thigh  upon  the  abdomen ;  as  when  a  person  is  struck  on  the  back 
with  a  heavy  weight,  or  is  thrown  forwards,  or  falls  whilst  carrying  a 
heavy  load  upon  his  shoulders,  when  the  upper  and  posterior  part  of  the 
joint  receives  the  whole  of  the  strain.  In  these  circumstances,  the  capsu¬ 
lar  ligament  is  ruptured,  and  the  bone  slips  out  of  its  articulation. 

The  Diagnosis  of  this  form  of  dislocation  is  easy  in  proportion  as  the 
head  of  the  bone  lies  high  on  the  dorsum  ilii.  The  more  it  sinks  towards 
and  into  the  sciatic  notch,  the  more  difficult  does  the  detection  of  the 
displacement  become,  and  the  greater  the  risk  of  its  being  overlooked 
altogether,  or  mistaken  for  a  sprain.  In  ordinary  cases  of  fracture  of 


Dislocation  below 
the  Tendon.  Much  in¬ 
version.  (Bigelow.) 


430 


SPECIAL  DISLOCATIONS. 


Fig.  186. 


the  neck  of  the  thigh-bone,  the  eversion  of  the  limb  at  once  points  out 
that  the  head  of  the  bone  is  not  dislocated  on  the  ilium.  The  only 
severe  injury  of  the  hip  with  which  the  dislocation  upwards  and  back¬ 
wards  can  be  confounded,  is  the  rare  case  of  fracture  of  the  neck  of  the 
thigh-hone^  with  inversion  of  the  limb.  In  this  accident,  the  increased 
mobility,  and  the  existence  of  crepitus,  will  enable  the  Surgeon  to 
effect  the  diagnosis.  Should,  however,  the  fracture  be  an  impacted 
extracapsular  one,  with  inversion,  then  the  difficulty  of  diagnosis  is 
undoubtedl}^  great.  A  correct  conclusion  may,  however,  be  arrived  at 
by  observing  that  in  the  fracture  the  flattened  trochanter  is  approximated 
to,  and  is  in  nearly  a  perpendicular  line  with,  the  anterior  superior  spine 
of  the  ilium  ;  whilst  in  the  dislocation  the  trochanter  is  diagonally  behind 
the  process  of  bone,  and  the  head  of  the  thigh-bone  can  be  felt  in  its 
new  situation  by  deep  manipulation  of  the  gluteal  region. 

Reduction  of  Iliac  Dislocation  by  Rotation. — The  patient  being  laid  on 
his  back  and  fnlly  anaesthetized,  the  Surgeon  flexes  the  thigh  upon  the 

abdomen,  so  that  the  head  of  the 
bone  is  lifted  out  from  behind 
the  acetabulum.  The  limb  should 
now  be  slowl}^  abducted,  and  ro¬ 
tated  outwards.  By  this  manoeu¬ 
vre  the  head  revolves  around  the 
great  trochanter,  which  is  fixed 
by  the  outer  branch  of  the  Y  -liga¬ 
ment,  and  rises  into  its  articular 
cavity.  The  movement  is  fa¬ 
cilitated  by  carrying  the  limb 
downwards  as  well  as  outwards. 
Bigelow  has  summarized  the 
movements  necessary  to  effect 
reduction  in  this  way  in  the  fol¬ 
lowing  words,  Lift  up^  bend 
out.,  roll  out.’’^  In  some  cases 
slight  rotation  inwards.,  instead 
of  outwards,  succeeds  best.  In 
others,  again,  it  may  be  neces¬ 
sary  for  the  Surgeon  to  place 
his  foot  on  the  anterior  superior  spinous  process,  to  steady  the  pelvis 
while  he  raises  the  bent  knee. 

Reduction  by  Extension  is  effected  in  the  following  manner.  The 
patient,  having  been  put  under  the  influence  of  chloroform,  is  laid  on 
ids  back  upon  a  strong  table  between  two  staples,  one  of  which  should 
be  fixed  to  the  floor  and  another  at  a  point  above  the  level  of  the  body, 
in  a  direct  line  with  the  axis  of  the  limb,  and  about  twelve  feet  apart. 
The  counterextending  force,  consisting  of  a  jack-towel  or  a  padded 
leather  belt,  must  then  be  passed  between  the  injured  thigh  and  the 
peringeum,  and  fixed  to  the  staple  in  the  floor.  The  pulleys  must  now 
be  attached  to  proper  straps,  or  to  a  towel  fixed  with  a  clove-hitch  knot 
immediately  above  the  knee,  by  one  end ;  the  other  extremity  being 
attached  to  the  staple  in  the  wall,  which  should  be  so  situated  as  to  be 
continuous  with  the  axis  of  the  lower  part  of  the  limb.  The  knee  being 
then  slightly  bent  and  rotated  inwards,  traction  is  applied  slowly  and 
steadily  until  the  head  of  the  bone  has  approached  the  acetabulum,  when 
the  Surgeon  rotates  the  limb  outwards  so  that  the  head  may  slip  into 


Dorsal  Dislocation.  Reduction  by  Rotation.  The 
limb  has  been  flexed  and  abducted,  and  it  remains 
only  to  evert  it  and  render  the  outer  Branch  of  the 
Y  -ligament  tense  by  Rotation.  (Bigelow.) 


REDUCTION  OF  ILIO-SCIATIC  DISLOCATION. 


431 


its  socket  (Fig.  181).  The  fact  of  the  reduction  being  accomplished  is 
ascertained  bj"  comparing  the  bon}"  points  of  the  limb  with  those  of  the 
opposite  side,  and  seeing  if  they  correspond.  A  long  splint  and  spica 
bandage  should  now  be  applied  to  fix  the  thigh,  and  the  patient  be  kept 


Fig.  187. 


in  bed  for  a  fortnight,  so  that  reunion  of  the  ruptured  tissues  may  take 
place.  In  reducing  this  dislocation,  there  is  some  danger  of  the  head  of 
the  bone  slipping  downwards  into  the  sciatic  notch,  if  the  limb  be  too 
much  raised.  This  accident,  which  has  happened  to  some  very  excellent 
Surgeons,  may  be  mistaken  for  reduction  of  the  bone  ;  a  serious  mistake, 
which  would,  unless  corrected,  entail  permanent  lameness. 

Reduction  of  recent  Dislocation  into  the  Sciatic  Notch  should  be  ef¬ 
fected  by  Manipulation.  This  may  usually  be  done  by  laying  the  patient 
flat  on  his  back,  fixing  the  pillow,  raising  the  thigh  at  a  right  angle  so 
as  to  unlock  the  head  of  the  bone  and  bring  it  below  the  acetabulum. 
It  may  be  jerked  into  this  cavity  by  bringing  the  foot  down  and  rota¬ 
ting  outwards  at  the  same  time. 

Sir  A.  Cooper  found  great  difficulty  in  the  reduction  of  the  disloca¬ 
tion  ;  and  he  and  Lisfranc,  amongst  other  Surgeons,  have  failed  to  reduce 
it  by  extension.  In  the  reduction  by  Extension^  the  patient  is  laid  on 
his  sound  side  instead  of  on  his  back,  and  extension  is  made  over  the 
middle  of  the  opposite  thigh  instead  of  immediately  above  the  knee,  as 
in  the  iliac  dislocation. 

In  either  of  these  dislocations,  if  difficulty  arise  in  raising  the  bone 
over  the  edge  of  the  acetabulum,  recourse  may  be 
had  to  the  plan  recommended  by  Sir  Astley  Cooper, 
of  lifting  the  head  of  the  bone  out  of  the  notch  and 
over  the  edge  of  the  acetabulum  by  means  of  a 
round  tow"el  placed  under  the  upper  part  of  the 
thigh  and  over  the  shoulders  of  an  assistant,  who 
first  stooping  and  at  the  same  time  resting  his  feet 
on  the  patient’s  pelvis,  should  then  raise  his  head 
and  draw  the  bone  towards  its  socket. 

Bigelow  describes  as  allied  to  the  sciatic  dis¬ 
location  (dislocation  below  the  tendon),  and  con¬ 
stituting  a  stage  of  it,  that  displacement  in  which 
the  head  of  the  bone  is  thrown  downwards  and 
outwards  towards  the  tuberosity  of  the  Ischium., 
lying  on  the  posterior  part  of  the  body  of  that 
bone  between  the  tuberosity  and  the  spine.  The 


Fig.  188. 


Tuberosity  below  Tendon. 
(Bigelow.) 


432 


SPECIAL  DISLOCATIOXS. 


head  of  the  bone  can  be  felt  in  this  situation ;  and  the  limb  is  inverted 
(Fig.  188).  Bigelow  considers  this  as  a  first  step  towards  luxation 
behind  the  tendon,  which  it  tends  to  become  when  the  patient  is  upright. 

2.  Dislocation  Doiunwards. — Of  this  class  of  dislocations,  that  on'^the 
Thyroid  Foramen  is  the  most  frequent.  In  it,  the  hip  is  flattened,  and 
the  promiuence  of  the  trochanter  completely  absent,  or  indeed  replaced 
b}'  a  depression.  The  limb  is  lengthened  by  about  two  inches,  advanced 
before  the  other,  and  considerably  abducted  (Fig.  189).  The  knee  is 
bent  and  incapable  of  extension ;  the  foot  usuallj^  points  forwards,  but 
is  sometimes  slightly  everted,  and  is  widely  separated  from  its  fellow. 
When  the  patient  stands,  the  bod}"  is  bent  forwards  in  consequence  of 
the  tension  of  the  psoas  and  iliac  muscles,  and  in  a  thin  person  the  bone 
may  be  felt  in  its  new  situation.  When  he  lies  on  his  back,  the  knee  is 
much  raised  and  the  thigh  flexed. 


Fig.  189. 


Thyroid  Dislocation.  (Bigelow.) 


Fig.  190. 


Reduction  by  Manipulation  in  Thyroid  Dislocation.  Rota¬ 
tion  and  Circumduction  Inwards  of  Head  of  Femur.  (Bige¬ 
low.) 


Causes. — This  dislocation  appears  to  be  occasioned  by  the  limb  being 
suddenly  and  violently  abducted,  as  by  falls  with  the  legs  widelj’’  sepa¬ 
rated  ;  in  consequence  of  which  the  head  of  the  bone  is  tilted  against 
the  inner  side  of  the  capsule,  and,  rupturing  this,  is  thrown  into  the  thy¬ 
roid  notch. 

Reduction  hy  Manipulation  must  be  done  as  follows.  The  limb  hav¬ 
ing  been  flexed  on  the  abdomen  so  as  to  bring  it  into  a  perpendicular 
position,  must  be  slightly  abducted  so  as  to  disengage  the  head  of  the 
bone.  The  thigh  is  then  to  be  strongly  rotated  inwards,  and  adducted, 
the  knee  being  carried  towards  the  floor  (Fig.  190). 

Reduction  hy  Extension  is  to  be  done  in  the  following  manner.  The 
patient  is  laid  on  his  back ;  the  counter-extending  girth,  or  towel,  is 
then  placed  around  the  pelvis  and  fixed  firmly  to  a  staple  next  to  the 
sound  side  of  the  patient.  A  padded  girth  is  then  to  be  placed  between 
the  perinseum  and  the  upper  part  of  the  dislocated  thigh.  From  this, 
extension  is  made  by  means  of  the  tourniquet  or  the  pulleys,  which  are 
fixed  to  a  staple  at  a  little  distance  from  the  injured  side  of  the  patient. 
Extension  having  then  been  made  to  such  a  degree  as  to  elevate  the  head 
of  the  bone  from  the  depression  in  which  it  lies,  the  Surgeon  passes  his 
hand  behind  the  sound  leg,  and,  seizing  the  ankle  of  the  injured  limb. 


REDUCTION  OF  THYROID  DISLOCATION. 


433 


draws  it  backwards  and  to¬ 
wards  the  mesial  line,  taking 
care  to  keep  the  knee  straight, 
and  thus  throwing  the  head  of 
the  bone  into  the  acetabulum 
b}’’  the  action  of  a  long  lever 
(Fig.  191), 

The  following  are  more  rare 
forms  of  dislocation  down¬ 
wards. 

The  head  of  the  thigh-bone 


may  be  thrown  directly  down¬ 
wards^  so  as  to  rest  on  the  lower 
margin  of  the  acetabulum^  be¬ 
tween  the  sciatic  notch  and  the 
th3’roid  foramen.  Two  cases 
of  this  injury  liave  been  re¬ 
corded  by  Gurne}^  of  Camborne 
and  one  b}^  Luke.  In  it  there 
is  less  eversion  of  the  limb  than 
in  the  thyroid  dislocation  (Fig. 

192).  Bigelow  has  pointed  out 
that  the  head  of  the  bone,  when 
thrown  below  the  lower  mar¬ 
gin  of  the  acetabulum,  ma}"  be 
further  displaced  ;  either  back¬ 
wards  on  the  dorsum  ilii,  or 
forwards  to  the  thyroid  fora¬ 
men.  In  extreme  flexion,  how¬ 
ever,  the  head  may  pass  down 
as  far  as  the  tuberosity  or  the  as¬ 
cending  ramus  of  the  ischium ; 
in  the  former  case  the  limb  is 

everted,  and  in  the  latter  inverted,  and  in  all  cases  flexed.  The  head  of 
the  bone  maj^also  pass  into  the  perinseuin  so  as  to  be  felt  inlts  abnormal 


Reduction  of  Dislocation  into  Obtura  or  Foramen  by 

Extension. 


Fig.  192. 


Dislocation  directly  downwards. 
(Bigelow. ) 


Fig.  193. 


Dislocation  Downwards  and  Inwards 
towards  Perinaeum,  (Bigelow). 


situation  behind  the  scrotum.  It  has  been  known  to  compress  the  urethra, 
and  thus  give  rise  to  retention  of  urine.  The  thigh  is  extremely’ abducted 
and  stands  out  at  a  right  angle  with  the  bod^"  j  and  the  toes  maj’  be 
VOL.  I. — 28 


484 


SPECIAL  DISLOCATIONS. 


either  inverted  or  everted — which  is  ascribed  by  Bigelow  to  the  want  of 
firm  bearing  for  the  trochanter  in  the  perinmum  (Fig.  193). 

In  the  Reduction  by  Manipulation  of  these  two  rare  forms  of  disloca¬ 
tion  downwards,  the  thigh  is  to  be  bent  and  its  head  guided  towards  the 
socket.  During  this,  the  dislocation  is  sometimes  converted  into  one  of 
the  thyroid  or  sciatic  variety.  In  the  dislocations  downwards,  vertical 
traction  and  slight  inward  rotation  may  be  used ;  in  the  dislocations 
downwards  and  outwards,  traction  upwards  and  inwards,  with  abduction 
and  rotation  outwards  ;  in  the  displacement  downwards  and  inwards, 
traction  upwards  and  outwards. 

Probably  allied  to  these  forms  of  dislocation  is  that  in  which  the  head 
of  the  bone  has  been  found  thrown  downwards  and  backwards  into  the 
lesser  sciatic  7iotch.  In  these  cases  there  is  considerable  shortening,  but 
the  position  of  the  limb  appears  to  vary.  In  an  instance  that  occurred  to 
Keate,  the  limb  was  abducted  and  the  toes  turned  outwards.  In  a  case 
reported  by  Wormald  the  limb  was  turned  inwards.  Although  the  limb 
is  described  as  shortened  in  these  cases,  Warren  has  related  a  case  in 
which  it  was  elongated. 

3.  Dislocation  Upivards. — The  dislocation  upwards  on  the  Pubic  Bone 
presents  veiy  unequivocal  signs.  The  hip  is  flattened;  the  head  of  the 
bone  can  be  distinctly  felt  lying  in  its  new  situation  above  Poupart’s 
ligament,  to  the  outer  side  of  the  femoral  vessels,  where  it  may  be  made 
to  roll  by  rotating  the  limb.  The  thigh  and  knee  are  slightly  flexed, 
rotated  outwards,  and  abducted;  the  limb,  which  is  separated  from  its 
fellow,  is  shortened  to  the  extent  of  an  inch  (Figs.  194,  195). 


Fig.  194. 


Fig.  195 


Pubic  Dislocation.  Head  of  Bone  in  Groin 
suspended  by  Y-ligament.  (Bigelow.) 


Pubic  Dislocation.  (Bigelow.) 


The  Cause  of  this  dislocation  is  either  direct  violence  applied  to  the 
back  of  the  thigh  whilst  the  limb  is  abducted ;  or  it  arises  from  the  pa¬ 
tient  making  a  false  step  in  walking,  and  suddenly  throwing  his  body 
backwards  in  order  to  avoid  a  fall,  twisting  and  displacing  the  limb. 

The  Reduction  by  Manipulation  should  be  eflfected  by  drawing  the 
limb  downwards,  and  at  the  same  time  raising  it  up  so  as  to  flex  it 
gradually  on  the  abdomen  as  the  head  of  the  femur  becomes  disentangled 


DISLOCATIONS  OF  FEMUE  UPWARDS. 


435 


from  its  position.  It  may  then  be  rotated  inwards,  and  the  head  of  the 
bone  thus  directed  towards  the  acetabulum. 

With  regard  to  the  Reduction  by  Extension^  Sir  Astley  Cooper  advises 
that  the  patient  should  lie  upon  his  back  with  his  legs  widely  separated ; 
and  that  counter-extension  being  then  made  by  a  girth  carried  between 
the  perinaeum  and  the  injured  thigh,  and  fixed  to  a  staple  in  front  of  and 
above  the  body,  the  pullies  should  be  fixed  upon  the  lower  part  of  the 
thigh,  and  the  extension  made  downwards  and  backwards.  After  this 
has  been  continued  for  a  suflicient  time,  an  assistant  lifts  the  head  of 
the  bone  by  means  of  a  towel  over  the  brim  of  the  acetabulum  (Fig.  196). 


Fig.  196. 


The  head  of  the  thigh-bone  may  also  be  thrown  under  the  anterior 
inferior  spinous  process^  constituting  the  Subspinous  Dislocation  of 
Bigelow.  There  is  shortening  of  the  limb,whch 
is  everted,  but  less  abducted  or  advanced  than  pjg  197^ 

in  the  dislocation  of  the  pubes.  The  head  of 
the  bone  can  be  felt  in  its  new  situation. 

In  the  dislocations  above  described,  the  Y- 
ligament  remains  entire.  Bigelow  describes 
also  Supraspinous  Dislocation  with  or  without 
rupture  of  the  outer  branch  of  thei  ligament. 

If  this  be  not  ruptured,  the  dislocation  is  called 
by  him  anterior  oblique :  in  it,  the  thigh  lies 
across  the  upper  part  of  the  corresponding 
limb,  and  is  firmly  locked  in  that  position,  with 
much  shortening  and  some  eversion.  Reduction 
may  be  effected  by  extension  of  the  limb  and 
increased  circumduction  across  the  symphysis, 

Avith  a  little  eversion  if  necessary  to  dislodge 
the  head  of  the  bone.  By  inward  rotation,  the 
head  of  the  bone  is  thrown  on  the  dorsum. 

In  the  true  supraspinous  dislocation^  the 
outer  branch  of  the  Y-ligament  is  ruptured : 
the  limb  is  shortened  and  everted.  In  a  case 
related  by  Cummins,  the  limb  was  shortened  c,  ^  . 

three  inches.  Keduction  may  be  effected  by  v-iigameat  n  stretched  across 
circumduction  inwards  and  eversion,  by  which  the  xeck  of  the  Bone,  which  lies 
the  dislocation  is  rendered  dorsal,  and  may  be  beneath  it.  (Bigelow.) 
thus  reduced  as  already  directed. 


436 


SPECIAL  DISLOCATIOXS. 


Everted  Dorsal  Dislocation  may  occur  when,  in  dislocation  on  the 
dorsum,  the  outer  branch  of  the  Y-ligament  is  broken:  the  integrity  of 
this  portion  being  necessary  for  the  eversion  of  the  limb. 

Irregular  Dislocations  of  the  head  of  the  thigh-bone  occur  when  the 
Y  -ligament  is  wholl}-  ruptured.  The  displacement  may  take  place  in  any 
of  the  above  described  directions :  but  the  characters  are  inconstant. 

Deduction  of  old  Dislocations  of  the  Hip-joint  is  attended  not  onl}’’  with 
great  difficulty,  but  with  no  small  amount  of  danger.  The  probability 
of  effecting  reduction  rapidly  decreases  with  the  length  of  time  that  the 
bone  has  been  left  unreduced,  and  this  more  in  some  dislocations  than 
in  others.  Thus  it  is  easier  to  reduce  an  old  dislocation  on  the  dorsum 
ilii  than  one  into  the  ischiatic  notch.  Dislocation  of  the  head  of  the 
thigh-bone  on  the  dorsum  of  the  ilium  may  usually  be  reduced  without 
any  great  increase  of  difficulty,  up  to  the  end  of  the  first  fortnight. 
After  that  time  the  difficulty  increases  considerably  ;  and,  although 
reduction  has  frequently  been  effected  in  these  cases  up  to  the  sixth  or 
eighth  week,  3’et  it  has  also  not  unfrequently  failed,  notwithstanding 
persevering  and  repeated  attempts.  After  two  months  have  elapsed,  the 
reduction  is  not  only  a  work  of  great  uncertainty,  but  also  of  no  slight 
danger  from  abscess  of  the  soft  parts,  or  fracture  of  the  femur ;  and  it 
is  then  seldom  practicable.  But  cases  have  been  reported,  and  are 
referred  to  at  p.  396,  in  which  these  dislocations  have  been  reduced  at  a 
much  later  period,  even  as  late  as  six  and  nine  months. 

If  the  bone  be  left  permanently  unreduced,  it  will  in  time  acquire  con¬ 
siderable  mobility,  more  particularly  if  l3dng  in  the  ischiatic  notch,  the 
patient  walking  readil}^  with  a  shortened  but  otherwise  useful  limb. 

The  attempt  to  reduce  old  dislocations  of  the  hip-joint  is  necessarily 
attended  with  danger.  In  some  cases  the  soft  parts  have  been  exten- 
sivel^Aacerated ;  in  others  fatal  inflammation  of  the  joint  has  ensued; 
and,  in  eleven  cases  wdth  which  I  am  acquainted,  the  thigh-bone  has  been 
fractured.  This  accident  has  happened  to  Surgeons  of  such  eminence  as 
Travers,  Yincent,  Malgaigne,  Phj’sick  of  Philadelphia,  to  Guynne  of 
Brighton,  to  Blackman  of  Cincinnati,  to  Harris  and  Randolph  of  the 
Penns^dvania  Hospital,  to  the  Surgeons  of  the  Xorthern  Hospital  of 
Liverpool,  and  to  a  practitioner  in  Loudon  now  living.  In  most  of  these 
cases  the  l3one  gave  way  at  its  neck  or  below  the  trochanters ;  the  dislo¬ 
cation  was  of  course  left  unreduced,  but  the  patients  recovered  without 
diflScult}',  the  fracture  being  treated  in  the  usual  waj^  The  cause  of  the 
fracture  usually  appears  to  have  been  the  emploj^ment  of  force  in  a 
transverse  or  rotary  manner  after  extension  had  been  kept  up  for  some 
considerable  time.  There  is  no  proof  that  undue  violence  was  used  in 
an}"  of  these  cases.  It  is  probable  that  in  some  the  femur  had  become 
weakened  by  disuse  of  the  limb. 

The  Complication  of  Fracture  of  the  Femur  loith  Dislocation  of  the 
Hip-joint  occasions  a  very  serious  state  of  things,  that  may  baffle  the 
most  skilful  efibrts  on  the  part  of  the  Surgeon.  The  line  of  practice 
to  be  adopted  must  depend  in  a  great  measure  on  the  seat  of  fracture. 
If  this  be  situated  below  the  middle  of  the  thigh,  the  limb  should  be 
put  up  tightly  in  temporary  splints,  and  an  attempt  made  under 
chloroform  to  reduce  the  dislocation  in  the  ordinary  way  by  pulleys 
applied  over  the  splints,  or  by  manipulation.  If  the  fracture  be  high 
up,  near  or  at  the  neck,  the  patient  should  be  put  under  chloroform, 
and  an  attempt  then  made  by  pressure  on  the  dislocated  head  and 
manipulation  to  replace  it.  It  is  possible  that  this  might  be  effected,  as 


DISLOCATIONS  OF  THE  PATELLA. 


437 


in  similar  injuries  of  the  humerus,  with  comparatively  little  trouble. 
Should  reduction  is  this  way  not  be  practicable,  we  may  adopt  the  plan 
successfully  employed  by  Bradley,  who,  in  a  lad  of  eighteen,  with  dislo¬ 
cation  on  the  dorsum  ilii,  and  fracture  of  the  displaced  bone,  allowed 
union  of  the  fracture  to  take  place,  and  then  at  the  end  of  five  weeks 
efiTected  reduction. 

Simulta7ieous  Dislocoiion  of  both  hips,  perhaps  in  different  directions, 
or  of  one  hip  with  fracture  of  the  opposite  thigh-bone,  has  been  met  with 
in  some  rare  instances.* 

Congenital  Bidocation  of  one  or  both  hips  is  occasion  all}’’  seen.  In 
these  cases  the  spine  is  bent  forwards  in  the  lumbar  region  (lordosis) ; 
the  trochanter  is  approached  to  the  anterior  superior  spine  of  the  ilium ; 
the  thigh  seems  shortened  ;  and  the  head  of  the  bone  ma}^  be  felt  on  the 
dorsum  ilii.  The  patient  walks  well,  but  with  a  peculiar  rolling  motion. 
There  is  little  to  be  done  in  the  wa}^  of  treatment  beyond  the  use  of 
mechanical  supports. 

Dislocations  of  the  Patella  are  not  frequently  met  with.  They 
may,  however,  occur  in  four  directions,  viz.,  outwards^  inwarda^  edge¬ 
wise  or  vertically^  and  upwards. 

1.  The  dislocation  Outwards  is  the  most  common  variety  of  the  acci¬ 
dent  ;  the  bone  being  thrown  upon  the  outer  side  of  the  external  condyle 
of  the  femur,  with  its  axis  directed  somewhat  backwards  and  downwards. 
The  knee  is  fiattened  in  front,  and  is  broader  than  usual ;  the  patella  can 
be  felt  in  its  new  situation,  and  the  muscles  that  form  the  quadriceps 
extensor  are  rendered  tense,  more  especially  the  vastus  internus ;  the 
leg  is  sometimes  extended,  but  more  frequentl}'-  the  knee  is  slightly 
flexed.  This  accident  usuall}^  happens  from  sudden  muscular  contrac¬ 
tion  in  persons  who  are  knock-kneed.  In  some  cases  it  has  been  occa¬ 
sioned  by  direct  violence,  driving  the  bone  out  of  its  position.  Most 
frequently,  the  patella  is  only  partially  displaced  outwards,  with  some 
rotation  of  the  bone  in  the  same  direction. 

2.  The  dislocation  Inwards  is  very  rare ;  Malgaigne,  who  has  investi¬ 
gated  this  subject,  is  of  opinion  that  there  is  only  one  case  of  the  kind 
on  record. 

In  these  lateral  dislocations.  Reduction  may  be  effected  by  laying  the 
patient  on  his  back,  bending  the  thigh  on  the  abdomen,  and  raising  the 
leg  so  as  to  relax  the  extensor  muscles.  The  Surgeon  then,  by  pressing 
down  that  edge  of  the  patella  which  is  furthest  from  the  middle  of  the 
joint,  raises  the  other  edge,  which,  being  tilted  over  the  condyles,  is 
immediately  drawn  into  position  by  the  action  of  the  extensors. 

3.  A  remarkable  form  of  dislocation  of  the  patella  is  that  in  which 
this  bone  becomes  twisted  upon  its  axis  in  such  a  way  that  it  is  placed 
Vertically.^  one  of  its  edges  being  fixed  between  the  condyles,  and  the 
other  projecting  under  the  skin,  and  pushing  this  forwards  into  a  dis¬ 
tinct  tumor.  In  some  cases,  as  those  of  Woolf  and  Mayo,  the  bone  has 
been  turned  almost  completel}^  round,  the  posterior  articular  surface 
becoming  partly  anterior.  The  signs  of  this  dislocation  are  evident, 
manual  examination  indicating  the  vertical  displacement  of  the  patella, 
with  a  deep  depression  on  each  side.  The  limb  is  completely  extended, 
flexion  being  impossible. 

This  peculiar  dislocation  is  of  very  rare  occurrence,  there  being  not 
more  than  ten  to  twelve  cases  on  record.  It  has  most  generally  arisen 
from  sharp  blows  or  severe  falls  upon  one  edge  of  the  patella,  whilst  the 
limb  has  been  semiflexed,  in  consequence  of  which  the  bone  appears  to 
have  been  semirotated  and  fixed  in  its  new  position.  Violent  muscular 


438 


SPECIAL  DISLOCATIONS. 


contraction,  however,  conjoined  with  a  twist  of  the  leg,  but  without  aii}^ 
blow,  has  been  known  to  produce  it  in  some  cases. 

The  Reduction  of  this  displacement  has  sometimes  been  very  diflScult; 
in  other  cases  it  has  been  readily  effected  ;  whilst  in  two  or  three 
instances  it  has  been  found  to  be  quite  impracticable;  Surgeons  having 
ineffectual!}^  attempted  by  means  of  elevators  and  the  section  of  the 
tendons  or  of  the  ligamentum  patellm,  to  replace  the  bone,  and  the 
patient  having  eventually  died  from  traumatic  suppuration  of  the  joint, 
with  the  displacement  unrelieved.  The  cause  of  this  difficulty  of  reduc¬ 
tion  is  not  very  distinctly  made  out ;  it  is  certainly  much  greater  than 
can  be  explained  by  simple  muscular  contraction,  and  may  not  improb¬ 
ably  be  owing  to  the  aponeurotic  structures  which  cover  the  bone 
becoming  twisted  or  entangled  under  it,  or,  as  Malgaigne  supposes,  to 
the  superior  angle  of  the  bone  being  wedged  in  the  suhcondyloid  space. 
If  relaxation  of  the  muscles  of  the  thigh,  and  the  employment  of  proper 
pressure  upon  the  patella,  do  not  succeed,  reduction  may  perhaps  be 
effected  by  the  patient  making  a  sudden  and  violent  muscular  effort  at 
extension  of  the  limb,  or  by  attempting  to  walk.  In  other  cases  the 
bone  has  been  readily  replaced  by  bending  the  leg,  and  rotating  it  on 
the  axis  of  the  tibia,  at  the  same  time  that  the  patella  is  pressed  into 
position,  as  Vincent  recommends.  Upon  the  whole,  forcible  flexion  of 
the  knee  aj^pears  to  have  answered  better  than  any  other  method,  and 
under  chloroform  will  probably  seldom  be  attended  by  difficulty.  Should 
these  plans  not  answer,  I  do  not  think  it  would  be  advisable  to  have 
recourse  to  subcutaneous  section  of  the  tendon  of  the  quadriceps  extensor 
and  of  the  ligamentum  patellae.  In  one  case  in  which  both  these  struc¬ 
tures  were  divided,  the  patella  remained  as  firmly  fixed  as  ever,  and  the 
patient  eventually  died  of  suppurative  inflammation  of  the  knee-joint ; 
and  in  no  case  in  which  division  has  been  i^ractised  does  it  appear  to 
have  facilitated  reduction. 

4.  Dislocation  of  the  patella  Upwards  can  only  occur  in  consequence 
of  the  rupture  of  its  ligament.  This  accident,  which  is  always  accom¬ 
panied  b}^  much  inflammation  of  the  joint,  requires  the  same  treatment 
as  a  fractured  patella. 

Dislocations  of  the  Knee. — This  joint,  owing  to  the  breadth  of 
its  articular  surfaces,  and  the  great  strength  of  its  ligaments,  is  seldom 
dislocated.  When  such  an  accident  happens,  it  usually  arises  from  falls 
from  a  great  height,  or  by  the  patient  jumping  from  a  carriage  in  mo¬ 
tion.  The  tibia  may  be  displaced  in  four  directions:  to  either  side^  for¬ 
wards^  or  backwards.  Besides  these  displacements,  the  joint  is  subject 
to  a  partial  luxation,  dependent  upon  displacement  of  the  semilunar 
cartilages. 

1.  The  Lateral  dislocations  of  the  tibia  are  the  most  common.  They 
are  always  incomplete.,  and  are  usually  accompanied  by  a  certain  degree 
of  rotation  of  the  limb  outward.  These  displacements  may  either  be 
External  or  Internal.  In  the  first,  the  outer  condjde  of  the  femur  rests 
upon  the  inner  articular  surface  of  the  tibia.  In  the  other,  the  inner 
condyle  is  placed  upon  the  outer  articular  surface  of  the  head  of  this 
bone.  In  either  case,  the  knee  is  slightly  flexed ;  there  is  a  marked 
sulcus  in  the  situation  of  the  ligamentum  patellae  ;  the  extensor  muscles 
of  the  thigh  are  relaxed,  and  the  deformity  of  the  joint  indicates  at  once 
the  nature  of  the  displacement. 

In  these  cases  Reduction  is  always  easy ;  indeed,  it  is  occasionally 
effected  by  the  unaided  efforts  of  the  patient  or  by  a  bystander.  It  may 
be  accomplished  by  flexing  the  thigh  upon  the  abdomen,  then  extending 


DISLOCATIONS  OF  THE  KNEE.  439 

the  leg,  and,  at  the  same  time,  by  a  movement  of  rotation,  replacing  the 
bones  in  their  proper  position. 

2.  The  dislocation  Backwards  may  be  complete  or  incomplete.  When 
it  is  complete,  the  posterior  ligament  of  the  joint  is  torn,  the  muscles  of 
the  ham  are  stretched,  the  limb  is  shortened  to  the  extent  of  an  inch  and 
a  half  or  two  inches,  and  is  semiflexed ;  the  head  of  the  tibia  can  be  felt 
in  the  ham,  and  there  is  a  deep  transverse  depression  in  front  of  the 
joint  immediately  below  the  patella. 

3.  The  dislocation  of  the  tibia  Forwards  is  of  more  frequent  occur¬ 
rence  than  the  last  accident.  In  it,  the  lower  end  of  the  femur  is  felt 
projecting  into  the  ham,  compressing  the  vessels  to  such  an  extent 
occasionally  as  to  arrest  the  circulation  through  the  lower  extremity, 
lacerating  the  ligaments,  and  stretching  the  muscles  in  this  situation. 
The  tibia  projects  forwards,  its  head  forming  a  considerable  prominence 
on  the  anterior  part  of  the  knee,  with  a  deep  depression  immediately 
above  it  and  the  patella,  which  is  rendered  more  evident  by  the  relaxa¬ 
tion  of  the  extensors  of  the  thigh ;  the  leg  is  usually  rotated  somewhat 
inwards  or  outwards,  and  there  is  shortening  to  the  extent  of  about  two 
inches. 

These  antero-posterior  dislocations  are  very  commonly  incomplete. 
When  this  is  the  case,  they  present  the  same  symptoms,  but  in  a  less 
marked  degree,  that  characterize  the  complete  displacements. 

In  the  Treatment  of  these  dislocations,  extension  should  be  made 
from  the  ankJe  whilst  the  thigh  is  fixed  in  a  semiflexed  position.  When 
the  leg  has  been  drawn  down  sufficiently,  proper  manipulation  will 
bring  the  bones  into  accurate  position  ;  splints  must  then  be  applied, 
means  taken  to  subdue  local  inflammation,  and  the  joint  kept  perfectly 
at  rest  for  two  or  three  weeks,  at  the  end  of  which  time  passive  motion 
may  be  commenced. 

Suhluxation  of  the  Knee.,  or  “internal  derangement  of  the  knee-joint,” 
is  a  more  frequent  accident  than  any  of  those  that  have  just  been 
described.  It  usualty  occurs  from  the  patient,  whilst  walking,  striking 
his  toe  against  or  tripping  upon  a  stone,  when  he  is  suddenly  seized 
with  acute  and  sickening  pain  in  the  knee,  often  so  severe  as  to  cause 
him  to  fall.  Before  doing  this,  however,  he  is  conscious  of  having 
strained  or  otherwise  injured  the  joint.  On  examination  it  will  be  found 
semiflexed,  the  patient  being  unable  to  extend  the  limb  i^roperl}",  and 
every  effort  being,  attended  b}^  severe  pain.  In  the  course  of  a  very  short 
time  the  joint  becomes  swollen,  being  distended  by  synovial  secretion; 
and  symptoms  of  subacute  synovitis  speedity  appear.  This  accident, 
originalty  described  by  Hey,  and  since  investigated  by  Sir  A.  Cooper 
and  others,  occurs  in  consequence  of  the  semilunar  fibro-cartilage  slip¬ 
ping  away  from  under  the  internal  cond3de,  either  before  or  behind  it,  so 
as  to  bring  the  surface  of  the  condyle  and  that  of  the  tibia  into  direct 
apposition.  The  severe  pain  that  is  always  experienced  is  owing  in  all 
probabilit}^,  to  the  nipping  of  the  loose  folds  of  s^movial  membrane  that 
lie  within  the  joint — the  so-called  mucous  and  alar  ligaments,  and  also 
to  the  great  stretching  of  the  ligaments  by  the  partial  displacement  of 
the  bones. 

The  Reduction  may  be  effected  by  flexing  the  joint,  and  then,  when 
the  muscles  are  off  their  guard,  the  patient’s  attention  being  directed 
elsewhere,  rapidly  extending  it  at  the  same  time  that  a  movement  of 
rotation  is  communicated  to  the  leg.  The  evidence  of  complete  reduc¬ 
tion  consists  in  the  restoration  of  the  power  of  extending  the  articulation. 
The  synovitis  that  usually  follows  this  injury  requires  to  be  treated  by 


440 


SPECIAL  DISLOCATIONS. 


local  anti-inflammatoiy  remedies  and  rest.  After  it  has  been  subdued, 
the  patient  should  wear  a  laced  knee-cap,  as  the  joint  will  be  weak,  and 
liable  to  a  recurrence  of  the  injury. 

Complications. — Dislocations  of  the  knee-joint  are  more  liable  to 
serious  complications  than  those  of  any  other  articulation.  Not  only 
are  the  ligaments  torn,  and  the  muscles  injured,  but  stretching,  and 
perhaps  laceration,  of  the  popliteal  vessels,  followed  by  gangrene  of  the 
limb,  may  occur;  or  the  joint  may  fall  into  a  state  of  suppurative  and 
destructive  inflammation. 

Compound  Dislocation  of  the  Knee-joint  is  one  of  the  most  serious 
injuries  to  which  the  limbs  are  liable;  the  external  w’ound  being  usually 
large,  ragged,  and  accompanied  b}’^  the  protrusion  of  the  condjdes  of  the 
femur,  with  much  laceration  of  the  soft  structures  in  the  vicinity  of  the 
joint.  These  are  cases  that  certainl}',  as  a  general  rule,  call  imperatively 
for  amputation;  indeed.  Sir  A.  Cooper  regards  this  injury  as  especiall}’' 
demanding  removal  of  the  limb.  Cases,  however,  have  occurred  in  which 
the  limb  has  been  saved.  Hence,  if  the  patient  be  young,  and  if  the 
vessels  of  the  ham  do  not  appear  to  have  been  seriously  injured,  the 
wound  in  the  soft  parts  at  the  same  time  not  being  very  extensive,  nor 
much  bruised,  an  attempt  may  with  propriety  be  made  to  save  the 
joint.  In  a  case  of  compound  dislocation  of  the  knee  forwards  in  a 
boy,  A.  White  sawed  off  the  projecting  end  of  the  femur  which  protruded 
through  the  ham,  and,  bringing  the  wound  together,  succeeded  in  saving 
the  limb. 

The  Head  of  the  Fibula  has  occasionally,  though  very  rarel}’,  been 
displaced  b}"  the  application  of  direct  violence.  Boyer  and  Sanson 
have  each  recorded  a  case  of  this  kind.  One  such  case  has  occurred  to 
me  in  my  practice.  It  happened  in  a  gentleman  about  23  years  of  age, 
who,  in  descending  an  Alpine  slope  covered  with  snow,  fell  with  one  leg 
bent  forcibly  under  him,  so  that  he  came  down,  as  it  were,  in  a  sitting 
posture.  The  head  of  the  fibula  was  thrown  Iback  off  the  articulating 
surface,  and  remained  permanentl}^  in  its  new  situation.  The  limb  was 
somewhat  weakened,  so  that  the  patient  could  not  jump,  but  otherwise 
he  suffered  no  inconvenience.  The  tendon  of  the  outer  hamstring  was 
veiy  tense,  and  when  I  saw  the  case,  some  time  after  the  accident,  its 
traction  effectuall}^  prevented  all  attempts  at  reduction. 

Dislocations  of  the  Ankle  occur  in  consequence  of  displacement  of 
the  astragalus  from  the  bones  of  the  leg,  whilst  it  continues  to  preserve 
its  normal  connection  with  the  rest  of  the  foot.  These  dislocations  are 
almost  invariably  connected  with  fracture  of  the  lower  end  of  the  fibula, 
or  of  the  inner  malleolus.  In  fact,  on  looking  at  the  arched  cavit}"  into 
which  the  astragalus  is  received,  it  is  evident  that  this  bone  can  scarcely 
be  displaced  laterall}'  without  fracture  of  one  side  of  this  arch.  In  con¬ 
sidering  these  dislocations  we  must,  in  accordance  with  the  general 
nomenclature  of  similar  accidents,  in  which  the  distal  part  is  alwa3"s 
said  to  be  displaced  from  the  proximal,  look  upon  the  foot  as  being 
dislocated  from  the  leg,  and  not  consider  the  tibia  as  being  displaced 
upon  the  foot.  The  direction  of  the  dislocation  must  consequent!}^  be 
determined  by  the  position  into  which  the  articular  surface  of  the 
astragalus  happens  to  be  thrown.  It  is  necessary  to  explain  this,  inas¬ 
much  as  a  good  deal  of  ambiguity  occurs  in  surgical  writings  from  the 
same  accident  being  described  differently,  according  to  the  view  taken 
of  the  part  displaced.  Thus,  Sir  A.  Cooper  speaks  of  the  tibia  as  being 
dislocated  at  the  ankle;  whilst  Boyer  and  others,  regarding  the  foot  as 


DISLOCATION’S  OF  THE  ANKLE. 


441 


the  part  displaced,  have  described  the  same  injury  in  directl}"  opposite 
terms. 

Dislocations  of  the  foot  from  the  bones  of  the  leg  may  take  place  in 
four  directions,  viz.,  to  either  side,  backivards,  or  forwards.  In  all  cases, 
the  injury  appears  to  be  occasioned  either  by  the  foot  being  twisted 
under  the  patient  in  jumping  or  running ;  or  else  by  its  being  suddenl}'’ 
arrested  b}''  coming  into  contact  with  the  ground  whilst  the  body  is 
carried  forwards.  But  these  twists  or  sprains  do  not  necessarily  occa¬ 
sion  dislocation,  and  must  not  be  confounded  with  that  accident. 

The  dislocation  Outwards  is  of  most  frequent  occurrence.  The  inner 
malleolus  projects  forcibly  against  the  skin.  The  deltoid  ligament  is 
either  ruptured  or  the  lower  end  of  the  inner  malleolus  broken  off;  there 
is  a  depression  above  the  outer  ankle  corresponding  to  a  fracture  of  the 
fibula ;  and  the  sole  of  the  foot  is  turned  upwards  and  outwards,  the 
inner  side  touching  the  ground,  whilst  the  outer  edge  is  turned  up. 

In  the  dislocation  Inwards,  wdiich  is  a  rare  accident,  and,  according  to 
Sir  A.  Cooper,  much  more  dangerous  than  that  just  described,  the  fibula 
is  not  fractured,  but  the  lower  end  of  the  tibia  is  splintered  off,  in  an 
oblique  manner  from  within  outwards.  The  outer  edge  of  the  sole  rests 
against  the  ground,  and  the  inner  side  is  turned  iq^. 

The  Reduction  of  these  lateral  displacements  is  readily  effected  by 
simple  traction  into  proper  position  ;  leg-splints  wdth  lateral  foot-pieces 
must  then  be  put  on,  or  Dupu3Tren’s  splint  ma^^  be  applied  on  the  same 
side  as  the  dislocation,  opposite  to  that  on  which  the  eversion  of  the 
foot  takes  place. 

In  the  dislocation  of  the  foot  Backwards,  the  deltoid  ligament  is  rup¬ 
tured,  the  fibula  probably  broken  in  the  usual  situation,  and  the  tibia 
thrown  forwards  on  the  navicular  and  internal  cuneiform  bones  ;  the  foot 
is  consequently  shortened,  the  heel  rendered  more  projecting,  and  the 
toes  pointing  downwards. 

The  dislocation  Forivards,  in  which  the  foot  is  lengthened,  and  the 
tibia  thrown!  upon  the  upper  and  posterior  surface  of  the  os  calcis,  behind 
tlie  astragalus,  is  an  accident  so  rare  as  seldom  to  have  been  witnessed, 
although  described. 

In  the  Treatment  of  these  antero-posterior  displacements  of  the  ankle, 
traction  of  the  foot  in  a  proper  direction,  the  leg  being  fixed  and  flexed 
upon  the  thigh,  will  readilj"  be  attended  by  replacement;  the  application 
of  lateral  splints  being  afteiwvards  sufficient  to  keep  the  parts  in  proper 
position. 

Compound  Dislocations  of  the  Ankle-joint  are  serious  and  b}^  no  means 
unfrequent  accidents,  the  displacement  occurring  in  the  same  direction 
and  from  the  same  causes  as  the  simple  forms  of  injuiy. 

The  Treatment  of  compound  dislocations  of  the  ankle-joint  must 
depend  to  a  considerable  extent  upon  the  amount  of  laceration  of  the 
soft  parts,  and  the  condition  of  the  bones  forming  the  arch  of  the  joint. 
If  the  w’ound  in  the  soft  parts  be  inconsiderable  in  extent,  clean  cut,  and 
with  little  injuiy  to  the  bones,  the  limbs  should  be  placed  on  a  M’ln- 
t^u'e’s  splint,  and  the  lips  of  the  wound,  being  well  cleaned,  brought 
together  by  strapping,  or  covered  by  lint  soaked  in  collodion  ;  evapora¬ 
ting  lotions  may  then  be  applied,  the  constitutional  condition  of  the 
patient  carefull}^  attended  to,  and  the  case  treated  in  much  the  same  way 
as  a  compound  fracture.  In  many  instances  this  plan  will  suffice,  and 
the  patient  will  recover  with  a  stiff  but  useful  limb,  the  joint  being  only 
partiall}"  ankylosed. 

If,  how'ever,  the  bones  be  projecting  and  comminuted,  and  the  soft 


442 


SPECIAL  DISLOCATIONS. 


parts  extensive!}’’  lacerated,  the  question  of  amputation  will  necessarily 
arise.  In  many  cases,  the  operation  may  be  dispensed  with  by  adopting 
the  treatment  recommended  by  Hey,  of  sawing  off  the  malleoli,  removing 
splinters  of  bone,  cleaning  the  w'ound,  bringing  together  its  edges  by 
simple  dressing,  and  supporting  the  limb  at  the  same  time  upon  a  M’ln- 
tyre’s  splint.  If  the  joint  be  still  more  seriously  injured,  the  posterior 
tibial  artery  torn,  or  the  foot  greatly  contused,  or  if  the  patient’s  consti¬ 
tution  be  shattered  and  irritable,  recourse  should  be  had  to  primary 
amputation.  I  believe,  however,  that  the  disinclination  on  the  part  of 
Surgeons  to  amputate  in  these  cases,  owing  to  the  strong  expression  of 
opinion  by  Sir  A.  Cooper  in  favor  of  the  attempt  to  save  the  limb,  has 
in  many  cases  been  carried  to  such  an  extent  as  seriously  to  endanger 
the  patient’s  life.  Secondary  amputation  may  be  rendered  necessary  in 
consequence  of  gangrene,  erysipelas,  or  extensive  suppuration. 

Dislocations  of  the  Astragalus. — The  astragalus  is  occasionally 
displaced  from  its  connection  with  the  bones  of  the  leg  above,  and  with 
those  of  the  tarsus  below,  being  thrown  either  forwards  or  backivards. 
The  displacement  forwards  happens  far  more  frequently  than  that  in  the 
opposite  direction.  In  the  dislocation  Forivards^  the  head  of  the  bone 
may  be  thrown  either  outwards  or  inwards;  but  I  do  not  think  there  is  any 
evidence  to  show  that  complete  lateral  dislocation  of  this  bone  can  occur 
irrespective  of  displacement  forwards  ;  the  so-called  lateral  dislocations 
being  displacements  of  the  bone  forwards,  with  twists  to  one  or  the  other 
side.  The  dislocation  forwards^  with  lateral  inclination,  may  either  be 
complete  or  incomplete.  When  it  is  complete.,  the  bone  is  thrown  out  of 
its  bed  on  the  calcaneum,  and  separated  from  its  connections  with  the 
malleolar  arch  above  and  the  scaphoid  in  front,  being  forced  in  front  of 
the  tarsus,  and  lying  upon  the  scaphoid  and  cuneiform  bones.  When 
the  dislocation  is  incomplete.,  the  head  is  separated  from  the  scaphoid, 
and  is  thrown  up  on  it,  or  on  the  external  cuneiform  or  cuboid  bones, 
the  body  of  the  astragalus  maintaining  its  connections  with  the  malleo¬ 
lar  arch  and  os  calcis.  The  dislocation  Backwards  is,  I  believe,  always 
complete.  In  the  luxation  backwards  there  is  no  rotation  of  the  bone, 
which  is  thrown  directly  behind  the  tibia,  in  the  space  between  it  and 
the  tendo  Achillis. 

These  dislocations  invariably  happen  from  falls  upon  or  twists  of  the 
foot ;  more  particularly  when  it  is  extended  upon  the  leg.  When  the 
foot  is  in  this  position,  the  lower  end  of  the  tibia  either  breaks  off  on 
the  application  of  sufficient  violence,  or  the  head  of  the  astragalus  is 
forced  out  of  the  cavity  of  the  scaphoid  and  its  bed  on  the  os  calcis;  the 
particular  kind  of  displacement  that  occurs  depending  upon  the  direction 
in  which  the  force  is  acting  and  in  which  the  foot  is  twisted.  And,  as 
the  foot  is  more  frequently  twisted  inwards,  the  head  of  the  astragalus 
is  thrown  outwards.  Dislocation  of  the  astragalus  differs  from  disloca¬ 
tion  of  the  foot  in  this — that  when  the  foot  is  dislocated,  the  astragalus, 
though  thrown  out  from  under  the  malleolar  arch,  preserves  its  connec¬ 
tions  with  the  rest  of  the  tarsus  ;  whilst  these  are  always  broken  through 
when  the  astragalus  is  the  bone  dislocated,  even  though  it  have  not  com¬ 
pletely  escaped  from  between  the  malleoli. 

The  dislocation  of  the  astragalus  forwards.,  with  twist  of  the  bone 
inwards.,  is  said  to  be  of  most  common  occurrence :  I  have,  however, 
more  frequently  witnessed  that  form  of  accident  in  which  the  bone  is 
thrown  somewhat  outivards  as  well  as  forwards.  In  either  case  the  dis¬ 
placed  bone  forms  a  distinct  tumor  upon  the  instep,  in  the  outline  of 
which  the  form  of  the  astragalus  can  be  distinctly  made  out.  Over  this. 


DISLOCATIONS  OF  THE  ASTRAGALUS. 


443 


the  skin  is  so  tightly  drawn  as  often  to  appear  to  be  on  the  point  of 
bursting.  When  the  bone  is  thrown  somew'hat  inwards,  the  foot  is  turned 
outwards,  and  the  internal  malleolus  projects  distinctly.  When  the 
astragalus  is  thrown  outvoards^  displacement  of  the  foot  inwards,  with 
great  projection  of  the  lower  end  of  the  fibula,  takes  place.  In  some 
cases,  fracture  of  the  neck  of  the  astragalus  is  conjoined  with  these  dis¬ 
locations  ;  and  not  uncommonly  the  luxation  is  compound  from  the  very 
first,  or  speedily  becomes  so  if  left  unreduced,  in  consequence  of  the 
sloughing  of  the  skin  which  covers  the  anterior  surface  of  the  bones,  the 
exj^osed  portion  of  w^hich  undergoes  necrosis,  and  perhaps  eventual 
exfoliation. 

The  dislocation  backwards^  into  the  hollow  under  the  tendo  Achillis, 
is  rare,  there  being  but  seven  recorded  instances  of  this  accident.  In 
the  majority  of  these  there  was  displacement  of  the  bone  imvards,  as  well 
as  backwards.  In  these  cases  the  diagnosis  is  eas}^  as  the  bone  forms 
a  distinct  prominence,  which  can  be  felt  under  the  tendo  Achillis. 

In  many  cases  the  dislocation  of  the  astragalus  is  not  altogether  com¬ 
plete,  a  portion  of  the  bone  still  intervening  between  the  under  surface 
of  the  tibia  and  the  upper  surface  of  the  os  calcis. 

Treatment. — The  reduction  of  this  dislocation  forwards.^  whether 
attended  by  lateral  displacement  or  not,  varies  greatly  in  facility ;  in 
some  instances  being  effected  with  the  greatest  possible  ease,  in  others 
being  attended  by  almost  insurmountable  difficulties.  This  difference 
depends,  I  think,  on  whether  the  dislocation  is  complete  or  not.  When 
the  astragalus  is  not  completely  thrown  from  under  the  arch  formed  by 
the  bones  of  the  leg,  a  portion  of  it  being  still  entangled  between  their 
articular  surfaces  and  that  of  the  calcaneum,  it  may  usually  be  readily 
reduced  by  relaxing  the  muscles  of  the  calf,  and  pushing  the  bone  back 
into  its  proper  position.  But  when  the  astragalus  is  completely  dislo¬ 
cated,  the  upper  surface  of  the  calcaneum  is  drawn  up  under  the  arch  of 
the  malleoli  b}’’  all  the  strength  of  the  muscles  that  pass  from  the  leg  to 
be  inserted  into  the  foot.  In  these  circumstances,  in  order  that  reduction 
take  place,  it  is  necessary  first  of  all  to  separate  the  articular  surfaces 
to  such  an  extent  as  to  admit  of  the  astragalus  being  pushed  back  into 
its  socket:  this  is  almost  impossible,  owing  to  the  great  perpendicular 
thickness  of  this  bone,  to  the  extent  to  which  it  is  consequently  neces¬ 
sary  to  draw  down  the  foot,  and  to  the  little  purchase  that  can  be  obtained 
on  it.  In  such  cases,  reduction  has  been  greatly  facilitated  by  the  division 
of  the  tendo  Achillis,  by  which  simple  operation  the  whole  strain  of  the 
muscles  of  the  calf  is  taken  off. 

If  the  reduction  be  still  impracticable,  and  the  bone  continue  unreduced 
and  irreducible  on  the  dorsum  of  the  foot,  what  should  be  done  ?  Two 
courses  present  themselves  to  the  Surgeon;  either  at  once  to  cut  down 
upon  the  astragalus  and  to  remove  it ;  or  to  adopt  a  palliative  treatment — 
to  put  the  limb  at  rest  on  a  splint,  to  apply  evaporating  lotions,  and  to 
wait  the  result,  acting  according  to  circumstances  as  they  develop  them¬ 
selves.  In  some  rare  cases  the  displaced  astragalus  has  given  rise  to 
comparative!}^  little  inconvenience ;  but  this  can  seldom  be  expected.  If 
the  dislocation  have  been  in  the  direction  forwards,  the  skin  will  usually 
slough,  and  then  a  portion  of  the  exposed  osseous  surface,  which  will 
probably  necrose,  may  be  excised,  or  the  whole  of  the  astragalus  may  be 
dissected  out  by  freely  exposing  it,  and  severing  its  ligamentous  attach¬ 
ments  ;  the  patient  recovering  with  a  somewhat  stiffened,  but  still  useful 
joint.  This  plan  appears  to  be  safer  than  excising  the  bone  in  the  first 
instance,  so  soon  as  the  dislocation  has  been  found  to  be  irreducible. 


444 


SPECIAL  DISLOC ATIOXS. 


Fio- 


198. 


In  luxation  backwards,  the  bone  has  not  hitherto  to  my  knowledge 
been  reduced,  except  in  one  case  which  occurred  in  Cniversit}^  College 
Hospital,  and  in  which  the  tibia  and  fibula  were  also  fractured.  It  is  by 
no  means  improbable  that  subcutaneous  division  of  the  tendo  Achillis 
may  in  future  enable  the  Surgeon  to  effect  reduction.  The  result  is, 
however,  satisfactory,  even  though  the  bone  be  not  reduced,  the  patient 
recovering  with  a  useful  foot.  If  the  dislocation  be  left  unreduced,  the 
soft  parts  covering  the  bone  may  slough,  as  happened  in  a  case  recorded 
b}"  R.  C.  Williams  of  Dublin,  in  which  the  bone  was  consequently  ex¬ 
tracted. 

In  Compound  Dislocation  of  the  Astragalus  (Fig.  198),  the  rule  of 
practice  must  depend  upon  the  extent  of  injury.  If  the  integuments 

have  merely  been  rent  in 
consequence  of  the  out¬ 
ward  pressure  of  the  dis¬ 
placed  bone,  an  attempt 
must  be  made  to  reduce 
the  dislocation,  aided,  if 
necessary,  by  the  division 
of  the  tendo  Achillis;  and, 
if  this  be  effected,  to  close 
the  wound  by  the  first  in¬ 
tention.  If  the  bone  be 
comminuted  as  well  as  dis¬ 
located,  the  proper  prac¬ 
tice  will  be  to  remove  the 
loosened  fragments,  and 
to  dress  the  wound  in  the 
simplest  manner,  allowing 
it  to  heal  b}”  granulation.  If  the  bone  be  irreducible,  it  is  a  question 
whether  it  should  be  left  or  dissected  out.  If  it  be  left,  the  wound  in 
the  integuments  will  certainly  extend  by  sloughing,  the  bone  will  in- 
fiame  and  become  carious  or  necrosed,  exfoliating  in  fragments,  and  the 
patient  will  only  recover  after  a  prolonged,  tedious,  and  dangerous  course 
of  treatment.  In  these  circumstances,  therefore,  it  appears  to  me  that  the 
simpler  and  safer  plan  both  to  limb  and  life  consists  in  enlarging  the 
wound  in  proper  directions,  so  as  to  dissect  out  the  irreducible  astragalus, 
and  then  bringing  the  articulating  surfaces  into  contact,  dressing  the  parts 
lightly,  and  trusting  to  the  formation  of  a  new  joint  between  the  tibia 
and  the  os  calcis.  So,  also,  if  a  simple  dislocation  of  the  astragalus 
become  compound  in  consequence  of  the  sloughing  of  the  superjacent 
tense  integuments,  the  exposed  and  necrosing  bone  should  be  removed 
in  part  or  in  whole,  according  to  the  circumstances  of  the  case.  If, 
together  with  the  dislocation  of  the  astragalus,  the  foot  be  extensively 
crushed,  amputation  maybe  required  either  at  the  ankle-joint  or  at  some 
convenient  part  of  the  leg. 

Dislocations  of  the  other  Tarsal  Bones  are  of  extremely  rare 
occurrence.  Most  of  these  bones,  however,  have  been  found  luxated  at 
times. 

The  Calcaneuin  and  Scaphoid,  carrying  with  them  the  rest  of  the  foot, 
are  sometimes  dislocated  from  the  astragalus,  which  is  left  in  situ  under  the 
malleolar  arch.  In  these  dislocations  the  bone  ma}’  be  displaced  in  either 
lateral  direction — outwards  or  inwards.  The  Treatment  consists  in  the 
flexion  of  the  leg  and  attempts  at  reduction  by  extension  of  the  foot  in 
the  ordinary  way.  If  moderate  extension  fail  in  effecting  reduction 


Dissection  of  Foot  in  Compound  Dislocation  of  Astragalus 

outwards. 


DISLOCATION  OF  THE  METATARSAL  BONES. 


445 


Pallsel  has  recommended  division  of  the  tendo  Achillis,  and,  if  neces- 
saiy,  of  the  posterior  tibial  tendon,  as  a  means  of  facilitating  this,  on  the 
same  principle  as  in  dislocation  of  the  astragalus. 

The  Calcaneiim  has  been  dislocated  laterally  from  its  connection  with 
the  cuboid  in  consequence  of  falls  from  a  height,  the  sufferer  alighting 
upon  his  heel.  Chelius  mentions  a  case  in  which  this  bone  w^as  dislocated 
b}’’  the  effort  of  drawing  off  a  tight  boot.  Reduction  seems  to  be  readily 
effected  by  relaxing  muscles,  and  pressing  the  bone  back  into  its  proper 
position. 

The  Scaphoid  and  Cuboid  Bones  have  been  dislocated  upwards,  in 
consequence  of  a  person  jumping  from  a  height  and  alighting  upon  the 
ball  of  the  foot.  In  these  instances  the  limb  is  shortened  and  curiousl}'’ 
distorted,  the  toes  pointing  downwards,  and  the  arch  of  the  instep 
being  increased  so  as  to  resemble  closely  enough  the  deformity  of  club¬ 
foot.  Reduction  may  be  effected  by  drawing  and  pressing  the  parts  into 
position. 

The  Great  Cuneiform  Bone  has  occasionally  been  found  to  be  dislo¬ 
cated.  Sir  A.  Cooper  mentions  an  instance  of  the  kind.  If  reduction 
be  not  effected  by  pressing  the  bone  into  its  position,  no  great  evil 
appears  to  result  to  the  patient,  the  motions  of  the  limb  not  being 
seriously  interfered  with. 

Sometimes  the  tarsal  joints  are  extensively  torn  open  without  ony  one 
bone  being  distinct!}"  dislocated.  I  have  seen  this  hajDpen  to  a  young 
man  who  caught  his  foot  between  the  spokes  of  a  revolving  wheel ;  the 
foot  was  violently  bent  and  twisted,  and  all  the  tarsal  joints  more  or 
less  torn  open.  Those  between  the  scaphoid  and  cuneiform  bones,  the 
calcaneo-cuboid  and  calcaneo-astragaloid,  as  well  as  the  ankle-joint  itself, 
were  especially  injured,  so  as  to  necessitate  amputation. 

Dislocation  of  the  Metatarsal  Bones,  though  excessively  rare, 
from  the  manner  in  which  these  bones  are  locked  into  the  tarsus,  and 
retained  by  short  and  strong  ligaments,  yet  occasionally  occurs.  In¬ 
stances  are  recorded  by  Dupuytren  and  Smith  :  Liston  mentions  a  case 
of  luxation  of  the  metatarsal  bone  of  the  great  toe  from  direct  violence; 
and  Tuffnell  records  a  case  of  luxation  downwards  and  backwards  of  the 
inner  three  metatarsal  bones,  from  a  fall  upon  the  leg  by  a  horse  rolling  on 
its  rider.  Two  cases  have  occurred  in  my  practice,  in  one  of  which,  by  the 
pressure  of  a  “  turn-table”  on  a  railway,  the  outer  three  metatarsal  bones 
were  dislocated  downwards.  In  the  other,  in  consequence  of  a  horse 
falling  and  rolling  on  its  rider,  there  was  a  compound  dislocation  of  the 
first  and  a  simple  dislocation  of  the  fourth  metatarsal  bone.  The  ques¬ 
tion  of  amputation  will  always  present  itself  in  these  cases,  and  must  be 
determined  on  general  principles,  by  the  age  of  the  patient,  and  the 
extent  of  injury  to  the  soft  parts. 

Luxations  of  the  Phalanges  of  the  Toes  but  rarely  happen,  and  present 
nothing  special  in  nature  or  treatment. 


446 


INJURIES  OF  THE  HEAD. 


INJURIES  OF  REGIONS. 


CHAPTER  XXIY. 

INJURIES  OF  THE  HEAD. 

Injuries  of  the  Head  are  among  the  most  important  subjects  that  can 
engage  the  Surgeon’s  attention.  Their  importance  is  derived  not  so 
much  from  the  mere  injury  of  the  scalp  and  skull,  as  from  the  implication 
of  the  brain  and  its  membranes,  and  the  results  which  are  thereby  pro¬ 
duced,  in  many  cases  directly,  and  in  others  indirectly  and  remotely, 
owing  to  the  anatomical  connections  and  consequent  close  pathological 
sympathies  that  subsist  between  the  external  and  internal  structures  of 
the  head.  In  consequence  of  this  tendency  to  cerebral  complication,  it 
is  of  the  first  moment  in  practice  to  study  these  injuries  as  a  whole,  with 
special  regard  to  the  affections  of  the  encephalon  that  are  produced  by 
them,  and  from  which  the  injury  of  the  scalp  and  the  fracture  of  the  skull 
derive  the  greater  part  of  their  interest.  It  is  therefore  necessary,  in 
the  first  instance,  to  be  acquainted  with  the  nature  and  treatment  of  the 
principal  forms  of  cerebral  affection  that  supervene  upon  these  accidents, 
before  we  proceed  to  study  the  nature  and  treatment  of  the  injuries 
themselves. 

CEREBRAL  COMPLICATIONS  OF  INJURIES  OF  THE  HEAD. 

These  may  be  primary  or  secondary.  The  brain  is  subject  to  three 
Iirincipal  Primary  States  of  Functional  Disturbance  arising  from  injury  ; 
viz.,  1.  Concussion,  2.  Compression,  and  3.  Cerebral  Irritation.  Anyone 
of  these  may  be  followed  by,  or  be  complicated  with,  inflammatory 
actions  of  various  kinds,  that  derive  much  of  their  peculiar  character¬ 
istics  from  the  conditions  with  which  they  are  associated,  and  from  the 
injuries  by  which  they  are  occasioned. 

In  describing  these  different  conditions,  we  are  compelled  to  define  the 
symptoms  that  characterize  them  more  distinctly  than  is  the  case  in 
actual  practice,  where  they  are  not  so  closely  individualized,  and  become 
merg-ed  together  to  a  considerable  extent. 

1.  Concussion  of  the  Brain. — Concussion,  or  stunning,  appears  to 
be  a  shock  communicated  to  the  nervous  system  from  the  application  of 
such  external  violence  as  will  produce  commotion  of  the  substance  of  the 
brain,  or  interfere  with  the  circulation  through  it;  in  consequence  of 
which  its  functions  become  suspended,  usuallj’'  in  a  slight  and  transitory 
degree,  but  occasionally  to  such  an  extent  that  the  patient  does  not  rally 
for  many  hours  from  the  depressed  state  into  which  he  is  thrown,  and 
perhaps  sinks  without  recovery. 

The  Pathology  of  concussion  of  the  brain  is  very  obscure.  The  reason 
of  this  is  obvious;  few  people  die  from  simple  concussion.  In  those 


CONCUSSIOX  OF  THE  BR.A.IN. 


447 


cases  in  which  death  has  occurred  from  other  causes  during  a  state  of 
cerebral  concussion,  it  has  been  found  that  the  disturbance  of  the  func¬ 
tions  of  the  brain  constituting  concussion  has  been  due  to  actual  lesion 
of  its  substance.  In  some  cases,  the  vessels  of  the  brain  and  its  mem¬ 
branes  have  been  congested.  In  others,  again,  portions  of  the  cerebral 
substance,  vaiying  in  size  from  points  to  patches  an  inch  or  more  in 
diameter,  have  been  disintegrated  and  more  or  less  ecchymosed.  In  the 
more  severe  and  fatal  cases  of  concussion  of  the  brain,  the  cerebral  sub¬ 
stance  is  disorganized  to  a  much  greater  extent ;  in  fact,  in  these  cases 
the  characteristic  signs  of  contusion  of  the  brain  become  apparent. 

The  Sigiis  of  concussion  vary  according  to  the  severity  of  the  injury 
to  the  brain.  In  the  slighter  cases,  the  patient  may  merely  feel  giddy 
and  confused  for  a  few  minutes.  In  others,  consciousness  is  not  affected, 
but  he  feels  faint  and  weak,  being  unable  to  stand.  In  the  more  severe 
forms — in  that  degree,  indeed,  which  usuall3"  accompanies  any  severe 
injuiy  of  the  head — the  surface  becomes  cold  and  pale;  the  sufferer  is 
motionless  and  insensible,  or  onl}"  answers  when  spoken  to  in  a  loud 
voice,  relapsing  again  into  speedy' insensibilit}’’,  or  rather  semi-conscious¬ 
ness  :  the  pulse  is  feeble,  the  pupils  are  contracted,  and  the  sphincters 
usuall}'  relaxed ;  the  limbs  are  flaccid,  and  muscular  power  is  lost. 
After  this  condition,  which  is  the  first  stage  of  concussion,  has  lasted  for 
a  few  minutes  or  hours,  according  to  the  severity  of  the  shock,  the  second 
stage  comes  on  ;  the  circulation  gradual!}"  re-establishing  itself,  the  pulse 
becoming  fuller  and  the  surface  warmer.  About  this  time  the  patient 
veiy  commonl}"  vomits;  the  straining  accompanying  this  effort  appears 
to  be  of  service  in  stimulating  the  heart’s  action,  and  driving  the  blood 
with  more  vigor  to  the  paral^'zed  brain,  thus  tending  to  restore  its  func¬ 
tions  ;  and  we  according!}-  find  that,  after  vomiting,  the  sufferer  quickly 
rallies.  In  the  more  severe  cases  the  symptoms  that  have  just  been 
described  are  so  strongly  marked  that  the  patient  appears  to  be  mori¬ 
bund  ;  there  is  complete  prostration  of  all  nervous  and  physical  power ; 
the  surface  being  cold  and  death-like,  the  eyes  glassy,  the  pupils  either 
contracted  or  widely  dilated,  the  pulse  scarcely  perceptible  and  inter¬ 
mittent.  In  this  state  the  patient  may  lie  for  hours,  recovery  being  slow, 
and  the  concussion  merging  into  some  other  and  perhaps  more  serious 
affection  of  the  nervous  centres ;  or,  indeed,  in  some  cases,  speedily  ter¬ 
minating  in  death,  apparently  by  failure  of  the  heart’s  action.  But  it 
may  truly  be  said,  that  every  case  of  concussion  in  which  unconscious¬ 
ness,  though  but  momentary,  has  been  produced,  is  a  most  serious  one. 
Any  remote  evil  consequence  in  the  form  of  secondary  cerebral  disease 
may  possibly  ensue,  if  once  the  brain-substance  have  been  so  severely 
shaken  as  to  render  the  patient  unconscious,  even  though  the  insensi¬ 
bility  last  but  a  few  minutes.  All  such  cases  require  to  be  closely 
watched  and  carefully  managed  for  months  after  the  injury. 

The  Terminations  of  concussion  are  various.  We  have  already  seen 
that  in  some  cases  this  affection  may  speedily  give  way  to  complete 
recovery  ;  although  slight  headache,  some  degree  of  giddiness,  confusion 
of  thought,  and  inaptitude  for  mental  occupation,  may  last  for  a  few  days 
before  the  mental  powers  are  completely  re-established.  In  other  cases, 
the  concussion  may  rapidly  terminate  in  death  ;  but  between  these  con¬ 
ditions  there  are  several  intermediate  states.  Thus  recovery  may  be 
complete,  but  a  permanently  irritable  state  of  brain  may  be  left ;  the 
patient,  though  capable  of  the  ordinary  duties  of  life,  becoming  readily 
excited  by  slight  excesses  in  diet  or  in  the  use  of  stimulants,  or  by  mental 
emotion,  though  not  of  an  inordinate  intensity.  Individuals  thus  affected, 


448 


INJURIES  OF  THE  HEAD. 


suffering  from  a  preternaturally  irritable  brain,  frequently  die  suddenly 
in  the  course  of  a  few  months,  or  a  year  or  two,  after  the  receipt  of  the 
injury. 

In  other  cases  the  recovery  continues  to  be  incomplete ;  although  the 
patient  may  be  enabled  to  follow  his  usual  occupation,  and  to  mix  in  the 
ordinary  business  of  life,  j^et  his  state  is  j^recarious,  the  brain  being 
liable  to  the  occurence  of  inflammatory  disease  on  the  slightest  exciting 
cause.  In  snch  cases  as  these,  there  is  frequently  a  certain  degree  of 
impairment  of  mental  power,  the  meraoiy  failing  either  generally  or  in 
certain  important  points,  as  with  reference  to  dates,  persons,  places,  or 
language.  The  speech  is  perhaps  indistinct  and  stuttering.  Asthenopia, 
with  perhaps  squinting  or  paralysis  of  the  eyelid,  may  be  left.  The 
bearing  may  be  impaired,  or  noises  of  various  kinds  set  up  in  the  ears. 
Epileptic  convulsions  occasionally’’  occur;  sometimes,  as  the  patient  is 
recovering  his  consciousness,  he  may  be  seized  with  a  severe  fit;  but 
more  commonly  the  convulsions  do  not  come  on  as  a  primary  consequence, 
but  rather  as  a  remote  secondary  result  of  the  brain-injuiy.  There  may 
be  diminution  or  loss  of  muscular  and  of  virile  power,  especially,  as 
Hennen  observes,  when  the  injury  has  been  inflicted  upon  the  back  of  the 
bead  ;  and  Holberton  has  noticed  that,  when  the  medulla  oblongata  has 
been  injured,  the  pulse  may  continue  preternaturally  slow — an  observa¬ 
tion  which  I  have  had  several  opportunities  of  confirming  in  injuries 
botli  of  the  medulla,  the  pons,  and  the  crura  cerebri.  For  these  symp¬ 
toms  to  occur,  it  is  by  no  means  necessary  that  the  original  local  injury 
should  have  been  severe.  In  some  cases,  the  whole  nervous  system 
appears  to  be  jarred  and  concussed  without  any  wound  or  apparent  sign 
of  external  injury  of  the  head.  At  first,  the  symptoms  of  concussion 
are  but  slight,  perhaps  even  none  are  apparent,  and  the  sufferer  con¬ 
gratulates  himself  on  his  escape  ;  but  gradually  impairment  of  nervous 
power,  manifesting  itself  in  one  or  other  of  the  ways  just  mentioned, 
comes  on,  and  the  health  continues  broken  through  life. 

In  other  cases,  again,  the  sy-mptoms  of  concussion  may  gradually 
terminate  in  those  of  compression ;  and  not  unfrequently  the  reaction 
that  comes  on,  passing  bey’ond  the  bounds  that  are  necessary'  for  the  re¬ 
establishment  of  the  healthy  functions  of  the  brain,  terminates  in 
inflammation.  Liston  has  truly  observed,  that  no  injury  of  the  head  is 
too  trival  to  be  despised,  or  too  serious  to  be  despaired  of. 

2.  Compression  of  the  Brain. — This  is  a  common  condition  in 
injuries  of  the  head,  arising  from  a  great  variety  of  causes; — from  the 
pressure  of  a  portion  of  bone,  of  blood  extravasated,  or  of  pus  formed 
within  the  skull,  or  from  a  foreign  body^  lodged  there.  In  whatever  way 
occasioned,  however,  the  symptoms,  although  presenting  some  differences, 
are  tolerably,  constant.  The  patient  lies  in  a  state  of  coma,  stupor,  or 
lethargy,  being  paralyzed  more  or  less  completely^  heavy',  insensible,  and 
drowsy’’,  not  answering  when  spoken  to,  or  only^  when  addressed  in  a  loud 
voice,  and  perhaps  shaking  at  the  same  time.  The  breathing  is  carried 
on  slowly  and  deeply,  with  a  stertorous  or  snoring  noise,  and  usually  a 
peculiar  blowing  of  the  lips.  The  stertor  appears  to  be  owing  to  paraly¬ 
sis  of  the  velum  pendulum  palati,  which,  hanging  down  as  an  inanimate 
curtain,  is  thrown  into  vibrations  during  expiration  by^  the  passage  of 
the  air  across  it ;  the  distension  of  the  cheeks  and  blowing  of  the  lips 
are  due  to  the  muscular  paraly’sis  of  these  parts.  One  or  both  i^upils 
are  dilated;  the  pulse  is  full,  often  slow;  the  feces  pass  involuntarily’’, 
from  paraly'sis  of  the  sphincter  ani,  and  the  urine  is  not  uncommonly 
retained,  from  paraly'sis  of  the  bladder ;  the  skin  may  be  cool,  but  in 


CEREBRAL  IRRITATION. 


449 


many  cases,  on  the  contrary,  is  rather  hot  and  perhaps  perspiring.  Not 
unfrequently  this  condition  of  stupor  alternates  with  paroxysms  of 
delirium,  or  of  local  convulsive  action.  This  state  of  coma  may  become 
complicated  by  S3miptoms  of  inflammation  :  and,  unless  the  cause  that 
produces  the  compression  be  removed,  it  usually  terminates  speedily  in 
death,  the  patient  gradually  sinking  into  more  complete  unconsciousness, 
and  dying  in  an  apoplectic  condition.  In  other,  but  much  rarer  cases, 
the  coma  rna^^  continue  almost  an  indefinite  time,  for  many  weeks  or  even 
months,  until  the  compressing  cause  is  removed,  when  the  patient  may 
recover  consciousness,  and  the  symptoms  suddenly  disappear. 

The  Diagnosis  between  concussion  and  coma  has  been  sufficiently 
indicated  in  the  preceding  description  not  to  require  special  mention 
here.  But  it  must  be  remembered  that,  in  maii}^  cases,  one  state  merges 
into  the  other,  so  that  the  symptoms  are  not  so  distinctl}'-  marked  as  has 
been  indicated ;  and  they  are  more  especially  obscured  when  associated 
with  inflammation. 

3.  Cerebral  Irritation. — The  third  form  of  primary  cerebral  dis¬ 
turbance  which  is  met  with  in  injuries  of  the  head,  differs  very  remark¬ 
ably  from  botli  the  preceding.  The  patient  presents  symptoms  neither  of 
concussion  nor  of  compression,  nor  is  there  any  combination  of  the 
phenomena  characterizing  these  two  states ;  but  the  symptoms  are 
altogether  peculiar.  For  convenience  of  description,  they  may  be  divided 
into  two  groups,  the  bodily  and  the  mental. 

The  Bodily  Symptoms  are  as  follow.  The  attitude  of  the  patient  is 
peculiar  and  most  characteristic  : — lie  lies  on  the  side,  and  is  curled  up 
in  a  state  of  general  flexion.  The  bod}^  is  bent  forwards,  the  knees  are 
drawn  up  on  the  abdomen,  the  legs  bent,  the  arms  flexed,  and  the  hands 
drawn  in.  He  does  not  lie  motionless,  but  is  restless,  and  often,  when 
irritated,  tosses  himself  about.  But,  however  restless  he  may  be,  he 
never  stretches  himself  out  nor  assumes  the  supine  position,  but  invari¬ 
able  reverts  to  the  attitude  of  flexion.  The  ej^elids  are  firmly  closed, 
and  he  resists  violentlj^  every  effort  made  to  open  them ;  if  this  be 
effected,  the  pupils  will  be  found  to  be  contracted.  Tlie  surface  is  pale 
and  cool,  or  even  cold.  There  is  no  heat  of  head.  The  pulse  is  small, 
feeble  and  slow,  seldom  above  10.  The  sphincters  are  not  usually 
affected,  and  the  patient  will  pass  urine  when  the  bladder  requires  it  to 
be  emptied ;  there  may,  however,  though  rarel}^,  be  retention. 

The  Mental  state  is  equally  peculiar.  Irritability  of  mind  is  the  pre¬ 
vailing  characteristic.  The  patient  is  unconscious,  takes  no  heed  of  what 
passes,  unless  called  to  in  a  loud  tone  of  voice,  when  he  shows  signs  of 
irritability  of  temper,  or  frowns,  turns  awa^’’  hastily,  mutters  indistinctljq 
and  grinds  his  teeth.  It  appears  as  if  the  temper,  as  much  as  or  more 
than  the  intellect,  were  affected  in  this  condition.  He  sleeps  without 
stertor. 

The  course  taken  by  these  symptoms  is  as  follows.  After  a  period 
varying  from  one  week  to  three,  the  pulse  improves  in  tone,  the  tempera¬ 
ture  of  the  body  increases,  the  tendency  to  flexion  subsides,  and  the 
patient  lies  stretched  out.  The  mental  state  also  changes.  Irritability 
gives  way  to  fatuity ;  there  is  less  manifestation  of  temper,  but  more 
weakness  of  mind.  Recovery  is  slow,  but,  though  dela^^ed,  may  at 
length  be  perfect;  although  in  these,  as  in  all  other  cases  of  cerebral 
disturbance,  ulterior  consequences  may  be  manifested. 

This  form  of  cerebral  disturbance  may,  from  the  peculiar  irritability 
that  characterizes  it,  be  with  propriety"  termed  cerebral  irritation. 

The  symptoms  that  have  just  been  described  usually  follow  blows  upon 
VOL.  I. — 29 


450 


INJURIES  OF  THE  HEAD. 


the  temple  or  forehead,  and  probably  in  many  cases  may  arise  from,  or  are 
associated  with,  lacerations  of  the  cerebral  substance,  more  especially 
of  the  gray  matter. 

Contusion  of  the  Brain. — The  substance  of  the  brain  may  be  con¬ 
tused  or  lacerated  by  blows  upon  the  head.  This  is  most  common  at 
or  under  the  seat  of  injury,  or  it  may  occur  as  the  result  of  contrecoup^ 
at  an  opposite  point  in  the  same,  or  even  in  the  opposite  cerebral  hemi- 
sphere.  Being  struck  on  the  right  side  of  the  head,  the  patient  may  suf¬ 
fer  from  contusion  of  the  opposite  part  of  the  left  hemisphere,  or  vice 
vet'sd^  or  a  blow  on  the  occiput  may  occasion  laceration  of  the  anterior 
part  of  both  lateral  lobes.  In  this  injury  of  the  cerebral  substance,  we 
have  many  of  the  symptoms  that  are  characteristic  of  cerebral  irritation ; 
but  in  addition  to  them  there  is  occasionally  more  or  less  coma,  in  con¬ 
sequence  of  extravasation  of  blood,  or  there  may  be  paralysis,  facial  or 
hemiplegic.  In  other  circumstances,  or  possibly  associated  with  these 
conditions,  there  may  be  convulsive  movements  more  or  less  epileptiform 
in  character.  These  may  be  confined  to  the  face,  may  extend  to  the  para¬ 
lyzed  limbs,  or  may  occupy  both  sides  of  the  body. 

The  Pi'ognosis  in  these  cases  is  serious,  but  by  no  means  necessarily 
fatal.  In  fact,  in  the  majority  of  instances,  recovery  ensues. 

Effects  of  Cerebral  Injury  on  the  Mental  Powers. — The 
mental  condition  of  patients  who  are  recovering  or  who  have  recovered 
from  head-injury,  is  one  that  deserves  attentive  consideration.  It  will 
frequently  be  found  that  the  mental  powers  are  weakened,  either  gene¬ 
rally  or  in  one  special  direction.  The  memory  may  be  impaired  for 
words,  persons,  or  dates.  The  mind  cannot  grasp  a  subject  or  carry  out 
a  continuous  train  of  thought,  and  is  incapable  of  fixed  attention  or 
reasoning.  Delusions  of  various  kinds  may  occur,  especially  in  con¬ 
nection  with  the  mode  of  occurrence  of  the  accident.  I  have  known  a 
patient  to  give  the  most  consistent  and  detailed  accounts  of  the  mode 
in  which  his  head  was  injured,  vaiying  them  from  day  to  day;  and  every 
one  being  false,  but  believed  in  by  the  patient  at  the  time.  The  patient 
could  be  led,  by  a  process  of  questioning  and  suggestions  combined,  to 
give  almost  any  account  that  the  questioner  desired ;  and  this  with  great 
circumstantiality  of  detail.  This  is  a'  matter  of  much  interest  and 
importance  in  its  medico-legal  aspect,  as  it  is  evident  that  an  individual 
who  has  sustained  a  severe  injury  of  the  head  might,  in  perfect  good 
faith,  give  an  entirely  false  account  of  the  mode  of  the  infliction  of  the 
injury,  by  which  an  innocent  person  might  be  seriously  compromised. 

The  Secondary  Consequences  of  injury  to  the  brain  consist  of,  1, 
Inflammation  ;  and  2,  the  Deposit  of  Pus  and  other  inflammatory  exuda¬ 
tions  upon  or  within  that  organ  and  its  membranes. 

1.  Traumatic  Encephalitis. — Inflammation  of  the  brain  and  its 
membranes  from  injury  ( Traumatic  Encejjhalitis)  is  an  affection  of  great 
frequency  and  corresponding  importance.  It  is  specially  apt  to  super¬ 
vene  on  all  injuries  of  the  head;  though  the  liability  to  it  necessarily 
increases  with  the  severity  of  the  accident.  This  inflammation  of  the 
brain  and  its  membranes  may  set  in  with  great  intensity,  the  symptoms  of 
phrenitis  being  strongly  marked;  in  other  instances,  it  gradually  creeps 
on  in  a  slow  and  insidious  manner,  not  attracting  attention  until  it  has 
given  rise  to  some  severe  and  ulterior  consequences,  as  effusion  or  sup¬ 
puration,  when  its  symptoms  become  so  mixed  up  with  those  of  com¬ 
pression  and  of  irritation,  as  to  make  the  exact  diagnosis  of  the  patient’s 
condition  far  from  easy.  The  period  at  which  symptoms  of  inflamrna 
tion  of  the  brain  may  manifest  themselves,  after  an  injury  of  the  head 


TRAUMATIC  ENCEPHALITIS. 


451 


varies  greatly.  In  some  instances  they  set  in  almost  immediate!}’  on  the 
patient  recovering  from  the  effect  of  the  concussions ;  the  reaction  from 
this  state  gradually  assuming  an  inflammatory  character.  In  other 
cases,  it  is  not  until  after  several  days  that  inflammation  declares  itself; 
and,  again,  it  sometimes  happens  that  the  inflammatory  affection  does 
not  supervene  for  weeks  or  months :  but  then,  occurring  perhaps  under 
the  influence  of  comparative!}’  trivial  causes,  it  may  destroy  the  patient. 

Pathological  Changes. — After  death,  we  usually  find  both  the  brain 
and  its  membranes  inflamed.  The  arachnoid  is,  however,  the  structure 
that  appears  principally  to  suffer,  being  thickened,  so  as  to  become 
milky  and  semi-opaque.  Adherent  lymph  of  a  greenish-yellow  color  and 
opaque  purulent  appearance,  covers  one  or  both  hemispheres  of  the 
brain,  being  deposited  in  largest  quantity  at  the  seat  of  the  injury,  and 
not  unfrequently  extending  across  and  into  its  fissures,  occupying  espe¬ 
cially  the  depression  about  its  base.  The  vascularity  of  the  brain  and 
its  membranes  is  greatly  increased  ;  the  arachnoid  being  reddened  in 
patches,  and  .the  vessels  of  the  pia  mater  becoming  turgid  and  very 
numerous,  forming  a  vascular  network  over  the  surface  of  the  brain. 
The  sinuses  also  are  distended  with  blood  ;  the  cerebral  substance  ex¬ 
hibits  an  increase  in  the  quantity  of  red  points,  so  as  often  to  present  a 
somewhat  rosy  hue  ;  and  the  ventricles  are  filled  with  reddish  semi-turbid 
serum,  a  large  quantity  of  which  is  effused  about  the  base  of  the  brain. 
In  some  of  the  more  advanced  cases,  inflammatory  softening  of  the  cere¬ 
bral  substance  may  occur. 

8ymj)toms. — In  considering  the  symptoms  of  traumatic  encephalitis,  it 
is  useless  to  endeavor  to  make  a  distinction  between  the  inflammation  of 
the  brain  and  that  of  its  membranes  ;  the  two  structures  being  always 
more  or  less  implicated  at  the  same  time.  The  most  practical  division 
of  this  disease  following  injury,  is  into  the  acute  and  the  chronic  or  sub¬ 
acute  encephalitis. 

Acute  Encephalitis  usually  comes  on  within  eight-and-forty  hours  of 
the  infliction  of  the  injury.  The  patient  complains  of  severe,  constant, 
and  increasing  pain  in  his  head ;  the  scalp  is  hot,  the  carotids  beat 
forcibly,  the  pupils  are  contracted,  the  eyes  intolerant  of  light,  and 
the  ears  of  noise;  the  pulse  is  full,  vibrating,  and  bounding;  and  wake¬ 
fulness,  with  delirium,  usually  of  a  violent  character,  speedily  comes  on. 
All  the  symptoms  of  severe  constitutional  pyrexia  set  in  at  the  same 
time. 

Under  active  and  proper  treatment,  this  condition  may  gradually  sub¬ 
side  until  the  health  is  re-established,  but  more  commonly  the  symptoms 
of  inflammation  merge  into  those  of  compression:  the  delirium  becoming 
replaced  partly  or  in  whole  by  stupor,  from  which  the  patient  is  roused 
with  difficulty,  the  pupils  gradually  dilating,  the  breathing  becoming  heavy 
and  stertorous,  the  pulse  sometimes  continuing  with  its  former  rapidity, 
at  others  becoming  slow  and  oppressed.  The  skin  is  hot  but  clammy  ; 
the  patient  falls  into  a  heavy,  dull,  unconscious  state,  which  alternates 
with  convulsive  twitchings  or  jerkings,  and  occasional  delirious  out¬ 
breaks.  As  death  approaches,  the  sphincters  become  relaxed,  the  pulse 
more  feeble,  the  surface  cooler,  and  the  coma  more  intense  and  continu¬ 
ous,  until  the  patient  sinks  from  exhaustion  and  compression  conjoined. 
In  cases  of  this  kind,  pus  may  be  found  upon  the  surface  or  within  the 
substance  of  the  brain,  in  one  case  being  diffused,  in  the  other  collected 
into  a  more  or  less  distinctly  circumscribed  abscess.  In  other  cases, 
again,  the  symptoms  of  compression  appear  to  be  induced  by  a  thick 


452 


INJURIES  OF  THE  HEAD. 


layer  of  lymph  l34ng  upon  the  surface  of  the  brain,  or  a  quantity  of 
serous  fluid  being  poured  out  into  the  ventricles  and  about  the  base. 

Chronic  or  Subacute  Encephalitis  is  the  most  interesting  and  imj^or- 
tant  variety  of  inflammation  following  injuries  of  the  head.  It  may 
come  on  a  few  da^’s  after  the  infliction  of  the  injuiy,  or  not  until  months 
have  elapsed.  It  may  arise  from  accidents  that  simply  implicate  the 
skull,  as  well  as  from  those  that  directly  affect  the  brain  and  its  mem¬ 
branes.  The  patient  in  many  cases  has  apparently  recovered  entirely 
from  the  accident,  though  in  others  it  will  be  found  that  some  one 
s^unptom  indicative  of  the  brooding  mischief  still  continues,  such  as 
headache,  or  impairment  of  sight  or  of  hearing.  Occasionally,  the 
coming  mischief  is  foreshadowed  b}^  unusual  irritability  of  temper,  by 
loss  of  mental  vigor,  or  b^'  some  other  functional  disturbance  of  the 
brain.  In  such  cases  the  subacute  encephalitis  ma}-  suddenly  come  on, 
ushered  in  perhaps  b3"  an  aggravation  of  the  persistent  s^^mptom,  or  b}’’ 
an  epileptic  fit.  In  other  cases,  the  S3’mptoms  set  in  suddenty  without 
an3"  w'arning,  but  usually  with  much  intensity,  and  speedil3^  prove  fatal. 

The  Symptoms  of  subacute  encephalitis,  wdien  it  has  fairl3^  set  in, 
consist  of  those  of  inflammation,  irritation,  and  compression  of  the  brain 
conjoined ;  in  some  cases  one,  in  other  instances  another,  of  the  condi¬ 
tions  appearing  to  predominate.  The  irritation  and  inflammation  pro¬ 
ceed  from  the  increased  vascular  action  :  the  compression  from  the 
effusion  of  serous  fluid,  or  pus,  or  of  tymph.  The  S3unptoms  consist  of 
pain  in  the  head  wdth  heat  of  the  scalp,  and  either  dilatation  or  contrac¬ 
tion  of  the  pupils,  occasionalty  one  being  dilated  and  the  other  contracted. 
Squinting,  intolerance  of  light,  delirium,  moaning,  or  screaming,  uncon¬ 
sciousness,  wdth  convulsive  twdtchings  of  the  limbs  and  face,  commonly 
occur  with  the  ordinaiy  symptomatic  fever ;  and  lastty,  S3^mptoms  of 
coma,  rapidty  terminating  in  death. 

In  the  subacute  encephalitis,  the  same  appearances  are  very  generally 
found  after  death,  as  in  the  more  acute  form  of  the  afi’ection ;  but  com- 
moul3'  the  arachnoid  membrane  is  principalty  affected.  So  constantly  is 
this  the  case,  that  some  Surgeons  have  proposed,  and  not  altogether  with 
injustice,  to  appty  the  term  arachnitis  to  this  form  of  traumatic  ence¬ 
phalitis,  looking  upon  the  inflammation  of  the  arachnoid  as  the  principal 
lesion. 

2.  Intracranial  Suppuration. — This  may  be  of  three  distinct 
kinds  :  1.  Subcranial ;  2.  Intrameningeal ;  3.  Cerebral. 

1.  The  Subcranial  form  consists  in  the  deposit  of  pus  between  the 
skull  and  the  dura  mater.  It  alwa3's  occurs  at  the  point  struck,  and  is 
limited  or  circumscribed.  It  is  never  the  result  of  contrecoup. 

Three  conditions  may  lead  to  this  variety  of  intracranial  suppuration. 

a.  A  blow  on  the  head  w’hich,  with  or  wdthout  w^ound  of  the  scalp  or 
fracture  of  the  skull,  causes  a  separation  of  the  dura  mater  from  the 
bone,  leaving  a  hollow  in  which  inflammatoiy  effusions  and  eventualty 
pus  collect. 

b.  A  blow^  on  the  head  causing  necrosis  of  the  bone,  either  by  simple 
severe  contusion,  or  b3^  detaching  it  from  the  dura  mater  and  stripping 
oflf  the  pericranium — thus  disturbing  its  vascular  connections,  and  so 
giving  rise  to  suppuration  under  the  injured  portion  of  bone. 

c.  The  irritation  of  splinters  of  the  inner  table  in  cases  of  ordinar3^ 
depressed  or  of  punctured  fractures  of  the  skull,  causing  chronic  inflam¬ 
mation  of  the  dura  mater  and  eventual  suppuration.  In  these  cases  it 
is  often  found  associated  with  one  or  both  of  the  next  varieties. 

2.  The  Intrameningeal  form  consists  in  the  accumulation  of  pus,  or 


INTEACRANIAL  SUPPURATION. 


453 


of  greenish  piiriform  lymph,  in  the  cavity  of  the  arachnoid,  or  in  its 
deposit  in  the  pia  mater.  It  is  usually  widely  diffused,  most  generally 
beneath  the  part  struck ;  but  sometimes  on  the  opposite  side  of  the 
head,  ahvays  more  towards  the  vertex  than  in  any  other  part.  It  com¬ 
monly  occurs  in  persons  of  low  vitality — in  pysemic  cases — and  is  asso¬ 
ciated  with  typhoid  S3nnptoms. 

3.  The  Cerebral  form  is  usually  met  with  as  a  distinct  circumscribed 
abscess  in  the  white  substance  of  the  hemispheres,  often  associated  with 
the  last  variety,  and  occurring  in  individuals  of  low  or  unhealth}^  habit 
of  bod}^  It  may  occur:  I.  At  the  seat  of  injuiy;  2.  contrecoup ; 
or,  3.  It  may  be  the  consequence  of  the  lodgement  of  foreign  bodies  in 
the  brain. 

The  formation  of  pus  within  the  skull  is  a  sequence  of  much  interest 
in  injuries  of  the  head  ;  and  an  endeavor  has  been  made,  especially  b}^ 
Pott,  to  lay  down  rules  by  which  its  occurrence  ma}^  be  accurately 
determined.  Thus  it  has  been  said  that  if,  during  the  continuance  of 
encephalitis,  fits  of  shivering  come  on,  followed  b}’’  the  gradual  superven¬ 
tion  of  coma,  which  slowly  becomes  more  and  more  complete,  whilst  the 
constitutional  symptoms  of  inflammation  do  not  subside  ;  and,  if,  at  the 
same  time,  a  puffj^  swelling  form  upon  the  uninjured  scalp,  or  the  wound, 
if  an}",  become  pale  and  cease  to  secrete,  the  pericranium  separating 
from  the  bone,  which  is  seen  to  be  yellow-brown  and  dry,  an  abscess  w"ill 
have  formed  under  the  skull ;  and  further,  that  in  all  probability  its  seat 
will  correspond  to  these  changes  in  the  scalp  and  pericranium,  which  are 
due  to  the  bone  having  lost  it^s  vitality  by  being  separated  from  the  dura 
mater  by  the  subjacent  abscess. 

In  many  cases,  doubtless,  this  progression  of  constitutional  symptoms, 
accompanied  by  the  two  local  signs  just  mentioned,  has  afforded  proof 
of  the  existence  of  intracranial  suppuration.  It  but  seldom  happens, 
however,  that  the  signs  attending  the  formation  of  pus  within  the  skull 
occur  in  the  distinct  order  and  with  the  degree  of  precision  above  stated. 
In  the  great  majority  of  cases,  the  Surgeon  can  only  suspect  the  presence 
of  pus  from  the  symptoms  of  inflammation  terminating  in  paralysis  or 
coma.  But  he  cannot  say  "with  certainty  that  pus  has  formed,  for  the 
coma  may  arise  from  the  pressure  of  other  effusions  ;  but  if  the  puffy 
swelling  of  the  scalp  or  the  separation  of  the  pericranium  occur,  with 
exposure  of  dry  and  yellow  bone,  with  hemiplegia  on  the  opposite  side, 
then  he  may  feel  himself  justified  in  giving  a  more  positive  opinion  as  to 
its  existence  in  some  situation  within  the  cranial  cavity,  probably  be¬ 
neath  or  in  the  immediate  neighborhood  of  the  part  thus  affected. 

Pysemia^  with  its  characteristic  visceral  secondary  abscess,  is  by  no 
means  an  unfrequent  complication  of  injuries  of  the  head.  It  may  occur 
as  a  consequence  of  any  lesion  of  the  scalp,  skull,  or  brain,  in  which  the 
patient  survives  sufficiently  long  for  the  development  of  the  character¬ 
istic  phenomena  of  this  disease.  Hence  it  is  chiefly  after  the  slighter 
forms  of  cerebral  injury  that  pymmia  and  secondary  abscesses  have  been 
met  with  ;  occasionally  after  wounds  of  the  scalp,  rarely  after  those  of 
the  brain  or  its  membranes,  but  more  commonly  and  not  unfrequently 
after  injury  of  the  skull,  more  especially  after  severe  contusions  of  the 
bone  without  fracture. 

The  sequence  of  pathological  phenomena  in  these  cases  is  the  same 
that  is  observed  in  all  in  which  pyeemia  follows  injury  or  wound  of  the 
osseous  structures.  The  part  of  the  bone  that  is  struck  usually  necroses  ; 
inflammation  and  suppuration  are  set  up  in  the  surrounding  portions 
of  the  skull ;  the  cancelli  of  the  diploe  become  filled  with  pus  ;  its  veins. 


454 


INJUKIES  OF  THE  HEAD. 


wliich  are  large  and  sinuous,  inflame,  and  become  the  media  of  transmit¬ 
ting  pus  to  the  general  circulation;  the  ordinary  constitutional  S3mip- 
toms  of  pyaemia  develop  themselves,  and  secondary  abscesses  eventually 
form  in  the  lungs,  liver,  and  joints,  with  lowly  organized  jdastic  effusions 
into  the  serous  cavities,  more  particularly  those  of  the  pleura  and  peri¬ 
cardium.  The  older  writers  on  Surgery  had  noted  and  had  marvelled  at 
the  strange  phenomena  of  hepatic  abscess  following  slight  head-injuries, 
and  had  generally  overlooked  the  occurrence  of  secondary  deposits  in 
other  organs  and  structures.  More  modern  investigation  has  shown 
that  these  abscesses  are  p^^mmic,  that  the^"  are  a  part  of  a  general  puru¬ 
lent  infection  of  the  system,  and  that  they  almost  invariably  are  accom¬ 
panied  b^^  pulmonary  abscesses  :  indeed,  it  is  these  and  not  the  liepatic 
that  are  the  common  consequences  of  pymmia  resulting  from  cerebral 
injury.  Of  eighteen  cases,  P.  Hewett  found  the  lungs  studded  with 
abscesses  in  thirteen,  and  the  liver  in  three  ;  and  of  these  three,  in  one 
case  only  was  the  liver  alone  affected.  It  has  been  supposed  by  some 
that  intracranial  suppuration  is  a  necessaiy  precursor  of  these  secondary 
abscesses  :  that  it  frequently"  coexists  is  undoubted — we  often  meet  with 
pus  in  these  cases  between  the  dura  mater  and  the  contused  bone  ;  but 
to  suppose  that  it  is  a  necessaiy  concomitant,  is  an  error.  I  have  seen 
cases  in  which  the  most  extensive  secondary  deposits  were  found  in  the 
lungs,  liver,  joints,  etc.,  but  in  which  not  a  drop  of  pus  existed  in  the 
interior  of  the  skull  in  any"  part ;  but  I  have  never  seen  a  case  in  which 
the  diploe  around  the  injured  bone  did  not  contain  pus,  sometimes  dif¬ 
fused  through  its  cells,  sometimes  filling,  its  venous  sinuses. 

When  intracranial  suppuration  coexists  with  secondaiy  pymmic  depo¬ 
sits,  the  symptoms  of  the  two  conditions  become  so  mixed  up  as  to 
lead  to  considerable  difficulty  in  diagnosis ;  but  when  the  intracranial 
suppuration  is  not  developed,  there  may  be  a  complete  absence  of  all 
cerebral  disturbance,  whilst  the  alternating  rigors  and  heat  of  pymmia, 
the  oppressed  breathing,  or  the  hepatic  tenderness,  with  hiccup  or  recur¬ 
ring  sickness,  and  the  articular  tenderness,  give  unmistakable  evidence 
of  the  formation  of  secondaiy  abscesses. 

The  prognosis  of  these  cases  is  necessarily  most  unfavorable.  I  doubt 
much  whether  recovery  is  possible  when  once  py^mmia,  consequent  on 
head-injuiy,  has  advanced  to  the  formation  of  secondaiy  visceral  ab¬ 
scesses. 

Treatment. — The  treatment  of  these  various  cerebral  injuries,  and 
of  their  concomitant  affections,  is  one  of  the  most  important  and  diffi¬ 
cult  subjects  tliat  can  arrest  the  Surgeon’s  attention ;  the  difficulty 
depending  in  a  great  measure  on  the  various  conditions  that  have  just 
been  described  not  occurring  in  practice  with  that  amount  of  distinct¬ 
ness  and  individuality''  by  which  their  characters  can  alone  be  conveyed 
in  description,  but  being  associated  together  in  such  a  way  that  the 
exact  state  of  the  patient  cannot  so  readily^  be  made  out.  There  are 
few  cases,  indeed,  in  which  practical  tact  and  a  nice  discrimination  and 
analysis  of  sy^mptoms  are  more  required  than  in  those  now  under  con¬ 
sideration.  It  would,  however,  be  useless  to  attempt  to  describe  the 
shades  and  modifications  of  treatment  required  in  the  management  of 
the  different  groupings  of  these  various  forms  of  traumatic  cerebral  dis¬ 
turbance.  We  must,  therefore,  content  ourselves  with  describing  the 
treatment  of  each  state  broadly  and  separately,  and  leave  the  considera¬ 
tion  of  the  varieties  that  commonly'-  present  themselves  in  practice  to 
the  individual  tact  of  the  Surgeon. 

In  the  Treatment  of  Concussion,  the  first  great  indication  is  to  re- 


TREATMENT  OF  CONCUSSION. 


455 


establish  the  depressed  energies  of  the  circulation  and  of  the  nervous 
system.  In  effecting  this,  we  must  be  careful  not  to  overstimulate  the 
patient.  The  safest  practice  is  that  which  is  applicable  to  the  treatment 
of  shock  generall}’-; — to  wrap  the  patient  up  warmly  in  blankets,  to  put 
hot  bottles  around  him,  to  employ  frictions  to  the  surface,  and,  when 
he  is  sufficiently  recovered,  to  allow  him  to  swallow  a  small  quantity  of 
warm  tea.  Alcoholic  stimulants  of  all  kinds  should  be  avoided ;  unless 
the  depression  of  the  nervous  energy  be  so  great  that  reaction  cannot 
be  brought  about  without  their  agency.  But  an  enema  containing  some 
ether  or  aromatic  spirits  of  ammonia  may  be  administered. 

When  reaction  has  come  on,  steps  should  be  taken  to  prevent  the 
occurrence  of  inflammatory  mischief.  If  the  concussion  have  been 
slight,  it  may  be  quite  sufficient  to  purge  the  patient  well,  and  to  keep 
him  quiet  on  a  regulated  diet  for  a  few  da3’^s,  directing  him  carefully  to 
avoid  all  alcoholic  stimulants  and  mental  exertion  for  some  time.  If 
the  concussion  have  been  more  severe,  and  if  the  symptoms  of  reaction 
have  been  accompanied  by  indications  of  continuous  cerebral  disturbance, 
or  have  been  followed  by  giddiness,  headache,  or  confusion  of  thought, 
the  safer  plan  will  be  to  adopt  immediate  steps  for  the  prevention  of 
mischief.  The  patient  should  be  bled  generally",  or  locall}^  by  leeches 
and  cupping,  freely  purged,  kept  on  a  low  diet,  and,  above  all,  should 
remain  quiet  in  bed  for  some  days. 

Should  impairment  of  the  mental  faculties  or  senses  be  left,  the  more 
prudent, plan  will  be  to  have  recourse  to  a  mild  anti-inflammatoiy  treat¬ 
ment,  consisting  of  leeching,  cupping,  blistering,  the  introduction  of  a 
seton  in  the  nape  of  the  neck,  purging,  and  more  especiall3^  a  mild  mer¬ 
curial  course,  with  strict  avoidance  of  all  mental  and  bodil3^  stimula¬ 
tion.  The  patient  must  be  carefully  watched,  and  kept  under  proper 
supervision  for  some  length  of  time,  as  serious  s3uuptoms  are  apt  sud¬ 
denly  to  declare  themselves. 

When  Acute  Inflammation  of  the  Brain  or  its  Membranes  has  come 
on,  at  whatever  period  after  the  injuiy,  active  treatment  should  be  at 
once  adopted.  The  head  must  be  shaved,  and  an  ice-bladder  kept  con¬ 
stantly  applied.  Bleeding  from  the  arm,  repeated  as  often  as  the  pulse 
rises,  as  well  as  b3^  cupping,  or  leeches,  must  be  had  recourse  to ;  the 
bowels  should  be  freely  opened,  and  rigid  abstinence  must  be  enjoined, 
the  patient  at  the  same  time  being  confined  to  a  quiet  and  darkened 
room,  and  removed  from  all  causes  of  excitement  of  the  special  senses. 
Calomel  should  then  be  administered,  so  as  speedil3"  to  affect  the  mouth. 
As  the  disease  assumes  a  chronic  form,  the  same  general  plan  of  treat¬ 
ment,  modified  according  to  the  intensit3’'  of  the  infiammatoiy  affection, 
must  be  persevered  in,  the  patient  being  kept  for  a  length  of  time  after 
the  subsidence  of  all  the  S3unptoms  in  a  state  of  complete  quietude. 

The  Subacute  Encephalitis  which  occasionally  follows  injuries  of  the 
head,  even  at  a  remote  period  from  their  infliction,  is  most  dangerous 
and  unmanageable,  being  very  apt  to  terminate  in  loss  or  impairment  of 
sense,  in  diminution  of  intellectual  power,  or  in  local  paralysis.  Much 
of  the  difficult3’'  in  its  treatment  appears  to  arise  from  the  fact  that  the 
inflammation  is  often  low  and  eiysipelatous,  consequently  not  admitting 
active  depletoiy  measures. 

In  this  disorder  the  best  results  are  obtained  b3"  the  proper  adminis¬ 
tration  of  mercur3^  and  the  emplo3uuent  of  counter-irritants.  The  best 
mode  of  administering  the  mercuiy  is  to  give  half  a  grain  or  a  grain  of 
calomel  every  four  or  six  hours  until  the  gums  are  affected,  and  to  keep 
them  so  by  diminishing,  but  not  leaving  off  the  mineral.  The  repeated 


456 


INJURIES  OF  THE  HEAD. 


application  of  blisters  over  the  shaven  scalp  is  perhaps  the  most  useful 
form  of  counter-irritant ;  to  which,  in  more  chronic  cases,  a  seton  in  the 
neck  may  be  added.  So  long  as  any  s^unptoms  of  inflammation  con¬ 
tinue,  this  plan  of  treatment  must  be  steadily  kept  up. 

The  treatment  of  Cerebral  Irritation  that  I  have  found  most  success¬ 
ful,  is  of  a  negative  character,  and  consists  in  the  avoidance  of  all  active 
measures.  Xo  good,  but  much  harm,  may  result  from  bleeding,  purging, 
and  mercurializing  the  patient.  Complete  rest,  the  removal  of  all  men¬ 
tal  and  sensual  excitement,  shaving  the  head,  the  application  of  cold,  a 
mild  aperient  or  an  occasional  euema,  are  all  that  can  be  done  in  the 
way  of  medical  treatment.  As  the  constitutional  powers  are  depressed, 
they  must  not  be  too  much  lowered  by  complete  abstinence  from  food, 
and  small  quantities  of  stimulants  may  usually  be  advantageously  given. 
A  teaspoouful  of  brandy  in  a  little  water,  or  beef-tea,  eveiy  hour  or 
two,  according  to  the  condition  of  the  pulse  and  the  temperature  of  the 
skin,  will  generally  be  required.  In  some  cases,  where  there  is  great 
restlessness,  and  some  delirium,  without  any  sign  of  encephalitis  having 
supervened,  chloral  will  be  found  of  great  value,  or  an  opiate  even  may 
be  given  to  quiet  the  patient  and  induce  sleep.  This  cerebral  irritation 
is  the  only  form  of  primary  cerebral  disturbance  in  which  I  have  seen 
opiates  act  beneflcially ;  but  their  administration  requires  great  care, 
and  must  not  be  ventured  on  if  there  be  anj^  heat  of  head  or  quickness 
of  pulse.  In  other  instances,  again,  when  the  patient  has  been  very 
noisy,  shouting  and  ciying,  restless  and  sleepless,  I  have  found  chloral 
of  the  utmost  value  in  calming  the  mental  disquietude  at  once  and 
easil}'. 

In  all  cases  of  Coma  from  Compression^t\\Q  pressure  must  be  relieved 
before  it  can  be  expected  that  the  coma  will  subside.  But  besides  this 
great  and  obvious  indication,  which  must  be  carried  out  in  different 
waj’s  according  to  the  nature  of  the  compressing  cause,  there  are  certain 
general  considerations  to  be  attended  to,  b}^  which  the  patient’s  condi¬ 
tion  may  be  much  relieved.  Thus  the  bowels  should  be  freely  opened 
by  placing  a  drop  of  croton  oil,  mixed  with  a  little  mucilage,  in  the 
patient’s  mouth,  or  by  the  use  of  oleaginous  or  terbinthinate  enemata. 
The  urine  is  to  be  drawn  off  twice  in  the  twenty-four  hours,  the  room 
darkened,  and  kept  quiet,  and  ice  or  an  evaporating  lotion  applied  to 
the  head. 

When  symptoms  of  compression  occur  as  the  result  of  inflammation 
inside  the  skull^  the  treatment  becomes  surrounded  by  difficulties.  If, 
notwithstanding  anti-inflammatory  measures  have  been  pushed  to  their 
full  extent,  rigors  occur  and  coma  supervene,  conjoined  with  a  certain 
amount  of  continuous  inflammatory  action,  the  question  will  alwa3's 
arise  as  to  whether  trephining  should  be  had  recourse  to  on  the  suppo¬ 
sition  of  matter  having  formed.  In  these  cases  two  great  difficulties 
present  themselves  ;  the  first  has  reference  to  the  existence  of  pus  within 
the  skull,  and  the  second  to  its  situation. 

The  question  as  to  the  actual  existence  of  Pus  ivithin  the  SkulU  and 
to  the  dependence  of  the  symptoms  of  coma  upon  the  compression  exer¬ 
cised  by  the  purulent  deposit,  is  always  a  difficult  one  to  determine. 
There  are,  as  has  already'  been  stated,  no  absolute  and  unequivocal 
s^nnptoms  indicative  of  the  formation  of  pus  within  the  skull ;  s^nnptoms 
closely  simulating  those  that  accompaii}"  its  presence  being  often  pro¬ 
duced  b}"  the  effusion  of  serum,  or  of  puriform  l3nnph,  on  the  brain  or 
its  membranes.  But  although  there  may  not  be  au3"  symptom  that 
unequivocall3’  indicates  the  formation  of  pus  in  this  situation,  the 


TREATMENT  OF  INTRACRANIAL  SUPPURATION.  457 

Surgeon  is  not  unfrequently  enabled,  by  the  assemblage  of  general 
S3un;)toms  and  local  signs,  to  indicate  its  existence  with  considerable 
accuracy.  In  these  cases,  however,  it  is  usually  impossible  to  determine 
the  exact  seat  of  the  purulent  deposit  with  sufficient  precision  to  admit 
of  its  evacuation  by  the  trephine — whether  the  pus  be  between  the  skull 
and  the  dura  mater,  between  the  layers  of  the  arachnoid,  underneath 
this  membrane,  between  the  cerebral  convolutions,  or  deeply  seated  in 
the  substance  of  the  brain ;  whether  it  be  situated  under  the  seat  of 
injury  and  be  there  circumscribed;  or  whether  it  be  so  extensively 
diffused  as  not  to  be  capable  of  complete  evacuation.  That  these  diffi¬ 
culties  are  real,  must  be  obvious  to  every  practical  Surgeon  ;  and  in 
illustration  I  may  mention  the  following  two  cases,  out  of  many  that  I 
have  witnessed. 

A  man  was  admitted  into  University  College  Hospital  with  an  exten¬ 
sive  lacerated  wound  of  the  scalp,  denuding  the  pericranium.  He 
continued  free  from  all  cerebral  disturbance  until  the  tenth  day  after 
the  accident,  when  he  complained  of  headache,  and  had  a  quick  pulse 
and  a  hot  skin.  At  this  time  it  was  observed  that  the  denuded  pericra¬ 
nium  had  separated  from  the  skull.  He  was  treated  by  active  anti¬ 
inflammatory  means,  the  symptoms  subsiding,  and  went  on  favoral)ly 
until  the  thirty-fourth  day,  when  he  suddenly  became  delirious  and 
unconscious,  though  easily  roused  when  spoken  to  loudly,  and  then 
answering  rationally ;  his  pulse  fell  to  48.  He  died  on  the  thirt3’-ninth 
da}",  comatose.  On  examination  after  death,  the  pericranium  was  found 
detached  at  the  seat  of  injuiy ;  under  this  the  dura  mater  was  thick, 
3"ellow,  and  opaque,  but  no  pus  was  observable.  On  separating  the 
hemispheres,  however,  a  large  abscess  was  found  situated  deepl}-  in  the 
anterior  lobe  on  the  injured  side,  and  protruding  into  the  median  fissure. 
It  contained  about  one  ounce  of  pus.  In  such  a  case  as  this  trephining 
would  evidentl}"  have  been  useless ;  for,  although  it  was  probable  that 
there  was  pus  within  the  skull,  3"et  its  seat  could  not  have  been  diag¬ 
nosed,  and  the  abscess  could  never  have  been  reached. 

Another  case  that  was  admitted  into  the  Hospital,  was  that  of  a  man 
who  had  received  a  large  lacerated  wound  on  the  left  side  of  the  scalp 
in  consequence  of  a  fall.  There  was  no  injur}-  to  the  bone,  and  the 
patient  went  on  perfectly  well  until  the  seventy-seventh  day,  the  wound 
cicatrizing.  He  was  then  suddenly  seized  with  hemiplegia  of  the  right 
side,  from  which  he  recovered  partially  on  being  bled ;  some  twitching 
of  the  muscles,  however,  continued.  On  the  ninety-ninth  day  after  the 
accident  he  became  comatose,  and  was  trephined  by  S.  Cooper,  but 
without  relief,  dying  with  symptoms  of  compression  of  the  brain  on  the 
third  day  after  the  operation.  On  examination  thick  yellow  lymph  was 
found,  covering  the  whole  of  the  upper  surface  of  both  hemispheres, 
lying  between  the  arachnoid  and  pia  mater,  and  extending  into  the  sulci 
between-  the  convolutions.  There  was  an  abscess  in  the  substance  of 
the  brain  on  the  surface  of  the  riglit  hemisphere,  on  the  side  opposite 
to  the  seat  of  injury.  Here  also,  though  the  symptoms  were  well 
marked,  and  the  diagnosis  as  to  the  existence  of  pus  correct,  trephining 
was  useless,  as  the  pus  could  not  be  evacuated.  These  cases  serve  to 
indicate  the  difficulties  that  surround  any  operation  with  the  view  of 
evacuating  matter  from  within  the  cranium. 

When,  however,  the  symptoms  of  inflammation  have  been  interrupted 
by  an  attack  of  rigors,  followed  by  coma,  or  accompanied  by  hemiplegic 
paralysis  on  the  side  opposite  to  the  seat  of  injury,  with  the  formation 
of  a  puffy  swelling  of  the  scalp,  or  by  the  separation  of  the  pericranium 


458 


INJURIES  OF  THE  HEAD. 


and  the  exposure  of  yellow  and  dry  bone  at  the  bottom  of  the  wound, 
there  can  be  little  doubt  that  the  Surgeon,  though  bearing  in  mind  the 
extreme  uncertainty  of  the  case,  might  be  justified  in  trephining  at  the 
seat  of  local  change  or  of  injury,  in  the  hope  of  finding  or  evacuating 
pus  deposited  beneath  the  skull,  and  thus  giving  the  patient  his  only 
chance  of  life.  And  indeed,  if  the  local  changes  just  described  be  well 
marked,  the  bone  being  dry,  having  lost  its  vitality,  and  during  the 
operation  being  cut  without  bleeding  from  the  diploe,  the  probability  of 
finding  pus  immediately  beneath  the  trephine  aperture,  and  seeing  it 
well  up  by  the  side  of  the  instrument  as  the  bone  is  perforated,  is  very 
great.  And  should  it  not  be  met  with  there,  and  the  dura  mater  appear 
bulging  and  without  pulsation — for  the  absence  of  the  ordinary  pulsatile 
movement  of  the  brain  is  an  important  diagnostic  sign  in  these  cases, 
indicating  abscess  either  under  the  dura  mater  or  in  the  brain-substance — 
an  incision  might  even  be  made  through  this  membrane,  in  the  hope 
that,  the  abscess  being  circumscribed,  the  escape  of  the  pus  might  be 
facilitated.  Should  this  attempt  fail,  there  are  few  Surgeons  who  would 
have  the  hardihood  to  follow  the  example  of  Dupuytren,  who  plunged  a 
bistoury  into  the  substance  of  the  brain,  and  thus  luckily  relieved  the 
patient  of  an  abscess  in  this  situation.  Yet,  even,  though  pus  be 
actually  found  under  the  skull,  between  it  and  the  dura  mater,  and  be 
evacuated,  I  fear  that  the  patient’s  chances  of  recovery  will  not  be  very 
materially  increased,  as  the  encephalitis  will  continue,  and  eventuall}'- 
lead  to  his  death.  In  my  own  experience,  I  have  never  met  with  a  case 
of  recovery  in  these  circumstances;  and  P.  Hewett  states  that  the  suc¬ 
cessful  termination  of  a  case  of  trephining  for  pus  within  the  skull,  even 
between  it  and  the  dura  mater,  is  all  but  unknown  to  Surgeons  of  the 
present  da3^  Yet,  in  the  face  of  this  unfavorable  prospect,  it  appears 
to  me  that  trephining  is  the  proper  course  to  pursue.  There  can  be  no 
doubt  from  the  records  of  surgeiy,  that  patients  have  occasionally 
recovered  who  have  been  trephined  for  intracranial  suppuration ;  and, 
as  the  pus  cannot  evacuate  itself,  it  is  perfectl}^  certain  that  death  must 
ensue  if  it  be  not  let  out.  As  the  only  chance  of  life,  therefore,  rests 
wdth  the  trephine,  it  appears  to  me  to  be  proper  to  have  recourse  to  this, 
however  doubtful  ma^''  be  the  result. 

The  Treatment  of  Fysemia  from  injury  of  the  skull  must  be  conducted 
on  those  ordinary  medical  principles  that  guide  us  in  the  management 
of  pyaemia,  from  whatever  cause  arising.  There  is  only  one  point  of  a 
purel}’-  surgical  character  connected  with  it,  and  it  is  this:  Should 
recourse  be  had  to  trephining  in  cases  of  contusion  of  the  cranium  as  a 
means  of  preventing  the  development  of  pj^aemia  ?  In  answer  to  this,  I 
.would  say  that  experience  has  not  demonstrated  the  utility  of  this  pro¬ 
cedure;  that  it  is  impossible  in  any  given  case  of  contusion  of  the  cra¬ 
nium  to  sa^’-  whether  necrosis  or  suppuration  of  the  bruised  bone  will 
occur ;  that  it  is  extremely  difficult  to  limit  the  extent  of  that  probable 
necrosis,  and  to  remove  it  all  by  the  trephine ;  that  the  operation  itself 
is  attended  by  grave  dangers  of  its  own,  and  infiicts  an  additional  injury 
on  the  deploe ;  that  it  can  scarcely  be  considered  as  like!}'  to  be  attended 
b}^  any  benefit  in  rescuing  the  patient  from  the  possible  danger  of  P3^ae- 
mia  ;  and  that,  therefore,  in  the  face  of  such  uncertainties  and  of  such 
possible  dangers,  so  serious  an  operation  as  trephining  the  skull  is  not 
justifiable. 


CONTUSIONS  OF  THE  SCALP. 


459 


INJURIES  OF  THE  SCALP. 

Contusions  of  the  Scalp  from  blows  are  of  common  occurrence, 
and  present  some  peculiarities.  However  severe  the  contusion  may  be, 
it  seldom  happens  that  the  scalp  sloughs.  This  is  evidently  owing  to 
the  great  vascularity  and  consequent  active  vitalit}^  of  the  integuments 
of  the  head.  In  many  cases  a  contusion  in  this  situation  is  followed  by 
considerable  extravasation  of  blood,  raising  up  the  scalp  into  a  soft  semi- 
fluctuating  tumor.  It  occasionally  happens,  especially  in  blows  on  the 
heads  of  children,  that  this  extravasation  gives  rise  to  the  supposition 
that  fracture  exists,  owing  to  the  edge  of  the  contusion  feeling  hard, 
whilst  the  centre  is  soft,  apparentl}^  from  the  depression  of  the  subjacent 
bone.  In  some  cases,  indeed,  this  deceptive  feeling  will  occur  without 
any  considerable  extravasation  of  blood  under  the  scalp,  the  depressed 
centre  being  due  to  the  compression  of  the  scalp  by  the  blow  that  has 
been  inflicted  upon  it.  This  I  have  seen  occasionally  in  children  in  whom 
the  scalp  is  soft  and  somewhat  spongy.  The  difficulty  of  distinguishing 
between  such  an  extravasation  and  a  piece  of  depressed  bone,  is  often  so 
great  as  to  mislead  the  most  experienced  Surgeons.  Usually  it  can  be 
effected  by  feeling  the  smooth  bone  at  the  bottom  of  the  soft  central 
depression,  and  by  an  absence  of  symptoms  of  compression.  But  in  the 
event  of  doubt,  it  will  be  safer  to  make  an  incision,  and  so  to  examine 
directly  the  state  of  the  bone  itself. 

The  Treatment  of  contusion  of  the  scalp  is  A^ery  simple;  the  continuous 
application  of  evaporating  lotions  being  usually  sufficient  for  the  removal 
of  all  effusion.  In  no  circumstances  should  a  puncture  be  made  or  the 
blood  let  out  in  any  way.  Contusions  of  the  scalp  in  girls  and  young 
women  have  been  followed  by  severe  neuralgic  pains  in  the  part  struck. 
This  affection  is  extremely  rebellious  to  treatment ;  but  in  two  cases 
which  I  have  seen,  after  lasting  for  a  long  time,  these  symptoms  gradu¬ 
ally  disappeared.  In  such  cases,  incisions  down  to  the  bone  are  said  to 
have  sometimes  been  beneficial. 

Cephalhaematoma. — It  occasionall3Miappens  that  bloody  tumors  of 
the  scalp  form  in  newl}"  born  children,  either  from  contusion  of  the  head 
in  consequence  of  the  pressure  to  which  it  is  subjected  in  its  passage ;  or 
from  the  bruising  of  obstetric  instruments.  These  tumors,  wdiich  are 
often  large  and  fluctuating,  are  termed  cephalhsematomata.  They  may 
occur  in  two  situations,  either  between  the  aponeurotic  structures  of  the 
scalp  and  the  pericranium or  betiueen  this  membrane  and  the  skull  itself  . 

The  Subaponeurotic  Cephalhseinatoma  is  b}^  far  the  most  common 
variet3\  It  usuall}^  forms  a  large,  soft,  fluctuating  tumor,  situated  upon 
one  of  the  parietal  eminences,  and  having  a  somewhat  indurated  circum¬ 
ference.  The  tumor  may  usuall}^  be  made  to  subside  in  a  few  daj^s  by 
the  use  of  discutient  lotions. 

The  Subpericranial  Ce phalli sematom a  is  an  injuiy  of  extremely  rare 
occurrence  ;  but  Zeller,  Yalleix,  and  others  have  determined  its  existence. 
It  appears  as  a  fluctuating  tumor,  without  discoloration  of  the  scalp,  but 
with  a  hard  elevated  circle  around  it,  and  a  soft  depressed  centre,  almost 
communicating  the  sensation  of  a  hole  in  the  cranium.  Pressure,  how¬ 
ever,  gHes  rise  to  no  cerebral  s^nnptoms,  and  enables  the  Surgeon  to 
feel  the  osseous  lamina  at  the  bottom  of  the  depression.  These  tumors 
are  usuallj’’  small,  seldom  larger  than  a  walnut,  and  it  not  uncommonly 
happens  that  they  are  multiple.  It  is  worthy  of  note,  however,  that  each 
tumor  is  always  confined  to  a  separate  bone,  never  passing  beyond  the 
sutures,  where  the  adhesions  are  the  strongest  between  the  pericranium 


460 


INJUKIES  OF  THE  HEAD. 


and  the  subjacent  osseous  structure.  This  affection  is  said  to  be  most 
frequently  met  with  in  children  born  in  first  confinements,  and  is  more 
common  in  boys  than  in  girls  ;  according  to  Bouchard,  in  the  proportion 
of  thirty-four  to  nine. 

The  Pathology  of  this  affection  has  been  studied  by  Yalleix.  This 
Surgeon  found  that  the  pericranium  was  separated  from  the  bone  b}^  an 
extravasation  of  blood,  and  that  both  bone  and  pericranium  were  covered 
with  plastic  matter,  but  otherwise  healthy.  He  also  found  that  the  hard 
circle  surrounding  the  depression  was  formed  by  a  deposit  of  osseous  and 
plastic  matter  which  bounded  the  extravasation.  This  deposit  was 
effected  in  such  a  way  that,  on  a  transverse  section  being  made,  the  inner 
wall  was  found  nearly  perpendicular,  whilst  the  outer  sloped  down  upon 
the  cranium,  thus  giving  a  crateriform  appearance  to  the  margin  of  the 
tumor. 

The  Treatment  of  this  affection  must  be  conducted  upon  precisely  the 
same  principles  as  that  of  the  other  forms  of  scalp-extravasation. 

Wounds  of  the  Scalp  are  of  very  common  occurrence,  and  are  more 
serious  than  corresponding  injuries  elsewhere,  especially  in  persons  about 
the  middle  period  of  life,  and  of  unhealthy  or  broken  constitution.  Not 
only  are  those  injuries  more  likely  to  be  followed  by  erysipelas  than  those 
of  other  parts  of  the  bod}^  but  the  great  tendency  to  the  propagation  of 
inflammatory  mischief  inwards  to  the  encephalon,  and  to  the  com})lication 
of  cerebral  mischief,  often  accompanying  comparative!}^  slight  injuries  of 
the  scalp,  gives  to  these  accidents  much  of  their  serious  and  often  fatal 
character.  But,  though  there  be  this  danger  to  life  in  scalp-injuries, 
there  is  comparatively  little  risk  to  the  scalp  itself;  from  the  abundant 
supply  of  blood  which  it  receives  from  closely  subjacent  arteries,  and  its 
consequent  great  vitality,  sloughing  seldom  occurs,  even  though  the 
part  be  much  bruised  and  seriously  lacerated. 

The  Treatment  of  wound  of  the  scalp  necessarily  varies  somewhat 
according  to  the  nature  of  the  injury.  If  this  be  a  simple  cut,  it  will  be 
sufficient,  after  shaving  the  parts  around  and  cleansing  its  interior,  to 
bring  it  together  with  a  strip  or  tw’O  of  adhesive  plaster,  and  to  dress  it 
as  lightly  as  possible.  If  the  incision  in  the  scalp  be  extensive,  the  lips 
of  tlie  wound  must  be  brought  together  by  a  few  points  of  metallic  suture, 
or  by  harelip  pins.  If  there  be  arterial  hemorrhage,  this  may  usually  be 
best  arrested  by  passing  the  pins  across  and  under  the  bleeding  vessel, 
and  compressing  this  with  a  figure-of-8  suture.  In  this,  as  in  all  other 
cases  of  injury  of  the  head,  especial  attention  should  be  paid  to  the  state 
of  the  brain ;  for,  how'ever  slight  the  external  wound  may  be,  serious 
cerebral  mischief  may  have  been  occasioned  ;  or,  at  all  events,  the  same 
blow  that  has  caused  the  cut  in  the  scalp,  may  have  given  rise  to  such 
functional  derangement  of  the  brain  as  my  lead  to  the  worst  forms  of 
traumatic  encephalitis. 

It  more  frequently  happens  that  the  scalp  is  bruised  and  lacerated  as 
well  as  wounded  ;  and  very  commonly  that  a  large  flap  or  integument  is 
stripped  off  the  skull,  and  is  thrown  down  over  the  face  or  ear,  so  as 
to  denude  the  bones.  In  these  cases,  advantage  is  taken  of  the  great 
vitality  of  the  scalp.  However  extensively  contused  or  lacerated  this 
may  be,  however  much  it  may  be  begrimed  with  dirt,  it  is  a  golden  rule 
in  surgery  not  to  cut  any  portion  of  it  away,  but,  after  shaving  the  head 
and  ligaturing  any  bleeding  vessels,  to  wash  and  clean  it  thoroughly, 
and  replace  it  in  its  proper  position.  Here  it  must  be  retained  by  the 
support  of  a  few  strips  of  plaster,  or  by  the  application  of  a  suture  or 
two  at  the  points  of  greatest  traction  :  for  this  purpose,  thick  silver-wire 


TEEATMENT  OF  WOUND  OF  THE  SCALP. 


461 


is  better  than  silk  or  thread.  The  use  of  sutures  has  been  deprecated 
by  man}"  Surgeons  in  injuries  of  the  scalp,  as  tending  to  favor  erysipelas; 
and  undoubtedly  much  mischief  will  arise  if  an  attempt  be  made  to 
stitch  up  the  wound  closely,  and  in  small  wounds  sutures  are  generally 
unnecessary.  But  in  extensive  lacerations,  more  particularly  of  the 
anterior  part  of  the  scalp,  where  the  soft  parts  are  stripped  off,  and 
hang  over  the  occiput  as  the  patient  lies  down,  they  cannot  be  dispensed 
with ;  and  here  I  have  never  seen  any  but  the  best  consequences  follow 
their  use  at  those  points  where  the  torn  surfaces  can  be  readily  approxi¬ 
mated.  In  cases  of  this  kind,  the  under  surface  of  the  scalp  granulates, 
and  union  by  the  second  intention  takes  place  between  it  and  the  peri¬ 
cranium.  If  the  edges  do  not  come  properly  together,  a  piece  of  water¬ 
dressing  may  be  applied ;  but  the  head  must  be  kept  cool,  and  as  little 
bandaging  and  plastering  had  recourse  to  as  possible.  The  patient 
should  be  freely  purged,  and  kept  perfectly  at  rest  on  a  ratlier  low  diet ; 
any  cerebral  symptoms  that  occur  being  treated  in  accordance  wdtli  the 
principles  laid  down  in  discussing  traumatic  affections  of  the  brain.  In 
this  way  union  will  very  probably  take  place  through  the  greater  portion 
of  the  injured  surface;  should  it  not  do  so,  however,  or  should  anj^ 
part  slough,  granulations  spring  up,  and  reparative  action  goes  on 
with  surprising  rapidity.  If  pus  form  beneath  the  aponeurosis  of  the 
occipito-frontalis  muscle,  extensive  bagging  must  be  prevented  by  early 
counter-openings,  and  by  the  employment  of  coinj^ression  in  proper 
directions. 

The  pericranial  aponeurosis  or  tendon  of  the  occipito-frontalis  muscle 
is  firmly  attached  to  the  fat  and  fascia  superficial  to  it,  whilst  it  is  con¬ 
nected  in  the  loosest  manner  possible  with  the  parts  underneath.  This 
arrangement  is  often  of  great  service  in  protecting  the  skull  from  fracture, 
especially  when  the  head  is  caught  between  two  solid  bodies,  as,  for 
example,  the  wheel  of  a  cart  and  the  ground,  when  the  scalp  is  torn  off 
and  the  head  slips  awa}^,  so  escaping  further  injury.  In  suppuration 
occurring  under  the  tendon  of  the  occipito-frontalis,  the  pus  gravitates 
to  the  most  dependent  parts  until  arrested  by  the  attachments  of  the 
aponeurosis.  These  attachments  are  as  follows.  Posteriori}^,  the  fleshy 
bellies  are  attached  to  the  superior  curved  line  of  the  occipital  bone,  and 
the  space  between  them  is  filled  up  by  dense  fascia  similarly  attached. 
Laterally,  the  tendon  is  connected  with  the  attollens  and  attrahens 
aurem,  to  the  mastoid  process,  and  in  front  of  the  ear  to  the  zygoma. 
Pus  gravitating  in  this  direction,  therefore,  forms  a  bag  of  fluid  just 
above  the  zygoma,  never  extending  into  the  cheek.  In  front,  the  fleshy 
fibres  of  the  muscles  are  blended  with  those  of  the  corrugator  supercilii 
and  the  orbicularis  palpebrarum ;  while  in  the  middle  line  they  are  con¬ 
tinued  down  over  the  nose  into  those  of  the  pyramidalis  nasi ;  and  the 
pus  will  therefore  collect  in  the  upper  eyelids,  and  in  a  pouch  over  the 
root  of  the  nose. 

When  the  wound  is  too  tightly  closed,  the  discharges  force  their  way 
in  all  directions  in  the  loose  tissue  under  the  tendon,  giving  rise  to 
general  puffy  swelling  of  the  head  and  diffused  redness,  often  extending 
over  the  face ;  and  it  is  probable  that  this  state  of  things  has  often 
been  confounded  with  erysipelas,  and  has  given  rise  to  the  idea  that 
stitches  in  the  scalp  give  rise  to  that  disease.  If  simple  erysipelas 
supervene,  that  disease  will  require  to  be  treated  in  accordance  with 
ordinary  surgical  principles.  So  far  as  the  wound  in  the  scalp  is  con¬ 
cerned,  that  must  be  thrown  open,  all  dressings  removed,  and,  if  matter 
form,  a  free  outlet  must  be  afforded  to  the  pus.  If  diffuse  cellulitis 


I 


462  INJURIES  OF  THE  HEAD. 

occur,  free  incisions  must  be  made  through  the  puff}’  and  swollen  scalp, 
and  counter-openings  for  the  discharge  of  pus  and  sloughs. 

When  the  skull  itself  is  extensively  denuded  in  consequence  of  the 
pericranium  being  stripped  oflf  the  subjacent  bone  together  with  a  flap 
of  the  scalp,  it  does  not  necessarily  follow  that  necrosis  and  exfoliation 
of  the  exposed  bone  will  occur.  The  flap  must  be  laid  down  on  the 
denuded  osseous  surface,  to  which  it  may  possibly  contract  adhesion 
through  the  medium  of  granulations.  Should  it,  however,  slough,  and  a 
large  portion  of  the  skull  be  even  exposed,  exfoliation  of  the  outer  table, 
though  probable,  does  not  necessarily  happen  ;  for,  in  some  cases,  instead 
of  exfoliating,  the  exposed  portion  of  the  skull  will  inflame,  plastic  matter 
be  thrown  out,  and,  granulation  springing  up,  a  covering  be  formed  to 
the  bone. 


FRACTURES  OF  THE  SKULL. 

Injuries  of  the  Bones  of  the  Skull,  especially  Fracture,  possess  great 
interest,  not  so  much  from  the  lesion  of  the  bone  itself,  as  from  its  fre¬ 
quent  complication  with  injury  of  the  brain  and  its  membranes.  This 
cerebral  complication  may  either  be  produced  by  direct  injury,  the 
fragments  of  the  fractured  bone  compressing  or  wounding  the  brain  ;  or 
it  may  be  the  result  of  concussion  or  laceration  of  the  brain  by  the  same 
violence  that  causes  the  fracture. 

Contusion  of  the  Cranial  Bones  without  fracture,  occasioned 
either  by  ordinary  direct  violence  or  by  the  oblique  impact  of  bullets,  is 
a  very  serious  injury,  more  particularly  when  complicated  with  wound 
of  the  scalp.  In  it  there  are  three  sources  of  danger,  any  one  of  which 
may  be  followed  b}’  a  fatal  result;  viz.  :  1.  Xecrosis  of  the  part  of  bone 
struck,  leading  to  exfoliation  of  the  outer  table,  or  to  separation  of  the 
whole  thickness  of  the  cranium  and  exposure  of  the  dura  mater ;  2.  Sup¬ 
puration  under  the  skull,  between  it  and  the  dura  mater  ;  and,  3.  Pyaemia 
with  secondary  visceral  abscesses,  in  consequence  of  the  suppuration  of 
the  diploe  around  the  necrosed  point  of  bone,  and  the  entrance  of  pus 
into  the  cranial  veins — a  condition  to  which  reference  has  already  been 
made. 

Fractures  of  the  Skull  are  invariably  the  result  of  external  violence. 
This  may  act  directly  in  breaking  and  splintering  the  part  struck,  the 
fissures  often  extending  to  a  considerable  distance  and  detaching  large 
portions  of  the  skull ;  or  the  violence  may  act  in  an  indirect  manner, 
producing  the  fracture  either  without  being  applied  immediately  to  the 
cranium,  or  else  at  an  opposite  part  of  the  skull  to  that  which  is  struck. 
Thus  the  base  of  the  skull  may  be  fractured  by  the  shock  communicated 
to  it  when  a  person,  falling  from  a  height,  strikes  the  ground  heavily 
with  his  feet.  The  variety  of  indirect  fracture  in  which  the  lesion  occurs 
at  a  point  of  the  skull  opposite  to  that  which  has  been  struck,  is  the 
Fracture  hy  Contrecoup. 

Fracture  hy  Contrecoup  has  been  described  by  some  Surgeons  as  of 
frequent  occurrence,  whilst  it  has  been  denied  by  others.  There  can, 
however,  be  no  doubt  that  it  does  happen,  though  less  commonly,  per¬ 
haps,  than  is  generally  supposed.  Every  hospital  Surgeon  must  occa¬ 
sionally  have  seen  unequivocal  instances  of  it.  For  its  occurrence, 
several  conditions  are  necessary.  The  skull  must  be  struck  over  a  large 
surface,  as  when  a  person  falls  with  his  head  against  the  ground.  If  a 
blow  alight  on  a  thin  portion  of  it,  this  will  be  directly  fractured  ;  but 
if  a  dense  and  strong  part  of  the  bone  be  struck,  as  the  parietal  emi- 


FRACTURES  OF  THE  SKULL. 


463 


lienee,  or  the  lower  part  of  the  os  frontis,  the  shock  transmitted  through 
the  skull  geiierallly  will  cause  the  thinnest  and  most  brittle  portions  of 
it,  though  distant,  to  give  way  in  preference  to  the  stronger  part  on 
which  the  blow  has  immediate!}’  fallen.  The  fracture  by  contrecoup  is 
most  common  at  the  base  of  the  skull,  and  is  usually  much  radiated.  It 
is  always  fissured,  never  depressed. 

Simple  Fracture. — An  ordinary  simple  or  undepressed  fracture  of 
the  skull  consists  in  a  fissure,  sometimes  single,  at  other  times  starred, 
extending  often  to  a  considerable  distance  through  the  bones,  radiating 
sometimes  across  the  skull,  and  in  other  cases  completely  detaching  its 
upper  from  its  lower,  or  its  anterior  from  its  posterior  segment.  In  some 
cases  the  fracture  extends  into  one  of  the  sutures  ;  and  in  other  instances, 
which,  how'ever,  are  very  rare,  the  sutures  are  separated  without  any 
fracture. 

The  injury  usually  occurs  from  direct  violence,  but  is  also  the  only 
form  of  fracture  that  happens  by  contrecoup.  A  fissure  or  fracture,  such 
as  this,  gives  rise  to  no  signs  by  which  its  diagnosis  can  be  effected,  and 
often  escapes  detection  altogether,  more  particularly  when  the  scalp 
covering  it  is  not  wounded,  or,  if  contused,  w’hen  so  large  a  quantity  of 
blood  is  extravasated  as  to  render  it  impossible  for  the  Surgeon  to  feel 
the  subjacent  bone.  If,  however,  the  scalp  covering  the  injured  bone 
have  been  wounded,  its  existence  may  be  ascertained  by  running  the 
finger-nail,  or  the  end  of  a  probe,  over  the  exposed  surface  of  the  bone, 
or  by  seeing  a  fissure  into  which  the  blood  sinks. 

As  the  whole  importance  and  danger  of  fracture  of  the  skull  depends, 
not  upon  the  injury  that  the  bone  has  sustained,  but  on  the  concomitant 
or  secondary  lesions  of  which  the  contents  of  the  cranium  are  the  seat, 
no  special  Treatment  is  required  for  the  fracture  itself  when  simple  and 
undepressed,  the  Surgeon’s  whole  attention  being  directed  to  the  injury 
that  may  have  been  inflicted  on  the  brain  or  scalp.  Active  precautionary 
measures  should  be  adopted  without  delay,  with  the  view  of  guarding 
against  the  occurrence  of  inflammation  of  the  brain  and  its  membranes, 
even  though  no  symptoms  have  as  yet  declared  themselves.  So  soon 
as  the  patient  has  recovered  from  the  concussion,  his  head  should  be 
shaved,  an  ice-bladder  applied,  and  blood  taken  away  from  the  arm  ;  the 
bowels  should  be  well  opened,  and  the  room  kept  cool  and  quiet.  The 
employment  of  free  and,  if  need  be,  repeated  bleeding  is,  however,  of 
more  service  than  any  other  means,  and  should  never  be  omitted,  except 
in  feeble,  very  young,  or  aged  subjects. 

IwChronic Hydrocep)halus.f  the  cranial  bones  are  thinned  and  expanded ; 
but,  being  at  the  same  time  preternaturally  elastic  and  mobile,  are  seldom 
fractured.  When  they  are  so  injured,  the  presence  of  the  water  may  save 
the  brain  from  the  direct  eflfect  of  the  blow.  In  one  case  that  was  under 
my  care,  the  hydrocephalic  child  fell  from  the  top  of  a  house  on  to  its 
head,  and  sustained  a  long  fracture  through  the  left  side  of  the  skull,  but 
without  any  scalp-wound.  Shortly  after  the  accident,  a  large  soft  fluc¬ 
tuating  tumor  formed  under  the  scalp  opposite  the  line  of  fracture  ;  and, 
on  this  being  tapped,  about  three  ounces  of  hydrocephalic  fluid  was 
drawn  off.  This  operation  was  repeated,  but  the  child  died  about  ten 
days  after  the  injury,  with  hemiplegia  of  the  opposite  side,  and  con¬ 
vulsions. 

Fracture  of  the  Base  of  the  Skull. — The  most  serious,  and  indeed 
a  very  commonly  fatal  form  of  fissure  or  simple  fracture  of  the  skull,  is 
that  which  extends  through  its  base.  This  injury  is  usually  caused  by 
direct  violence,  as  by  a  fall  or  a  blow  upon  the  vertex  or  side  of  the  head, 


464 


INJURIES  OF  THE  HEAD. 


producing  a  fracture  which  extends  from  the  point  struck  across  the 
base  of  tlie  skull,  often  running  through  the  petrous  portion  of  the  tem¬ 
poral  bone  or  into  the  foramem  magnum.  It  may  also  take  place  as  the 
result  of  contrecoup^  or  by  indirect  violence,  as  when  a  person  falls  from 
a  height  on  his  head,  and  has  the  base  of  the  skull  broken  in  by  the 
w^eight  of  the  body  projecting  against  it ;  and  it  has  been  met  with  as 
the  consequence  of  alighting  on  the  feet  from  a  great  height,  when  the 
shock  has  fissured  the  occipital  bone  from  the  foramen  magnum.  The 
great  danger  in  these  cases*  arises  from  the  concomitant  injury  to  the 
brain,  either  by  direct  laceration  or  by  the  extravasation  of  blood  under 
it.  Though  most  usually  fatal,  these  injuries  are  not  invariably  so. 
Xot  only  does  it  occasionally  happen  that  patients  with  all  those  signs 
of  fracture  of  the  base  of  the  skull,  which  will  immediately  be  described, 

'  are  seen  to  make  a  complete  recovery,  but  in  the  different  Museums 
specimens  illustratwe  of  recovery  after  this  accident  may  be  met  with. 
Thus,  in  the  College  of  Surgeons’  Museum,  there  is  the  skull  of  a  person 
who  lived  two  years  after  a  fracture  of  its  base. 

Signs. — Fracture  of  the  base  of  the  skull  is  very  commonly  suspected  ’ 
when  symptoms  indicative  of  serious  injury  to  the  brain  speedily  follow 
a  severe  blow  upon  the  head.  Those  parts  of  the  nervous  centre  that 
are  most  important  to  life  are  more  liable  to  injury  in  this  than  in  other 
fractures  of  the  skull ;  the  same  violence  that  occasions  the  fracture 
injuring  the  contiguous  portions  of  brain,  or  lacerating  some  of  the  large 
venous  sinuses  at  the  base  of  the  skull,  and  thus  giving  rise  to  abundant 
intracranial  extravasation  of  blood.  These  sjunptoms  are  necessarily 
in  the  highest  degree  equivocal ;  and  much  anxiety  has  consequently 
been  evinced  by  Surgeons  to  discover  some  special  sign  of  the  occurrence 
of  this  particular  fracture. 

The  signs  of  fracture  of  the  base  of  the  skull  will  necessarily  vary 
according  to  the  seat  of  injury.  When  the  fissure  extends  through  the 
anterio7'  fossa,  there  may  be  extravasation  of  blood  into  the  orbit  or 
ej’elid,  or  free  hemorrhage  from  the  nose.  When  it  implicates  the  middle 
fossa,  there  is,  in  all  probabilit}^,  fracture  of  the  petrous  portion  of  the 
temporal  bone,  with  rupture  of  the  tympanum,  and  then  there  will  be 
bleeding  or  a  watery  discharge  from  the  ears.  When  \h.Q  posterior  fossa 
is  the  seat  of  injury,  the  signs  are  more  equivocal,  unless  the  fissure 
extend  forwards  to  the  petrous  portion  of  the  temporal  bone,  when  the 
more  characteristic  signs  will  occur. 

There  are  two  signs,  the  occurrence  of  which,  separately  or  together, 
leads  to  strong  presumptive  evidence  in  favor  of  the  existence  of  this 
kind  of  fracture.  These  are,  1.  The  Escape  of  Blood  from  the  interior 
of  the  Cranium  through  the  ears,  nose,  or  into  the  orbit ;  and  2.  The 
Discharge  of  a  Serous  Fluid  from  the  Ears,  and  occasionally  from  other 
parts  in  connection  with  the  base  of  the  skull. 

1.  The  occurrence  of  Bleeding  from  one  or  both  Ears  after  an  injury 
of  the  head  cannot  by  itself  be  considered  a  sign  of  much  importance, 
as  it  may  arise  from  any  violence  by  which  the  tympanum  is  ruptured, 
without  the  skull  being  necessarily  fractured.  If,  however,  the  hemor¬ 
rhage  be  considerable,  trickling  slowly  out  of  the  meatus  in  a  continuous 
stream,  if  the  blood  with  which  the  external  ear  is  filled  pulsate,  and 
more  especiall}^  if  the  bleeding  be  associated  with  other  symptoms 
indicative  of  serious  mischief  within  the  head,  and  if  it  have  been  occa¬ 
sioned  by  a  degree  of  violence  sufficient  to  fracture  the  skull,  we  may 
look  upon  its  supervention  as  a  strong  presumption  that  a  fracture  of 
the  base  of  the  skull,  extending  into  the  petrous  portion  of  the  temporal 


FRACTURE  OF  THE  BASE  OF  THE  SKULL. 


465 


bone,  has  taken  place,  and  that,  perhaps,  one  of  the  venous  sinuses  in 
its  neighborhood  is  torn. 

Hemorrhage  into  the  Areolar  Tissue  of  the  Orbit  and  Eyelid^  giving 
rise  to  extensive  eccbj-mosis  of  the  lid,  possibly  with  protrusion  of  the 
eyeball  itself,  often  accompanies  fracture  of  the  orbital  plate  of  the 
frontal  bone.  The  ecchymosis  that  occurs  in  these  cases  arises  from  the 
filtration  of  the  blood  from  the  interior  of  the  skull,  through  the  frac¬ 
ture,  into  the  loose  areolar  tissue  contiguous  to  the  injured  bone.  It 
differs  remarkably  in  appearance  from  that  resulting  from  a  direct  blow 
upon  the  eyelid — from  a  “  black  eye.’’  In  the  latter  case  there  is  bruis¬ 
ing  of  the  skin,  and  the  ecchj^mosis  is  in  a  great  measure  cutaneous,  of  a 
reddish-purple  color.  In  the  ecchymosis  from  fracture,  the  hemorrhage 
is  entirely  subcutaneous  and  submucous  :  there  is  probably  no  bruising 
of  the  eyelid,  but  this  is  tense,  greatly  swollen,  and  of  a  purple  color. 
The  extravasation  appears  under  the  ocular  conjunctiva  in  a  very  marked 
manner,  which  is  rarely  the  case  in  an  ordinary  black  03^0,  where  the 
ecchymosis  is  superficial  to  the  palpebral  ligament,  and  shut  off*  from 
the  subconjunctival  areolar  tissue.  This  hemorrhage  may  be  venous  or 
arterial.  When  venous  it  probably  arises  from  laceration  of  the  cav¬ 
ernous  sinuses.  When  arterial,  it  may,  as  Hewitt  has  shown,  be  the 
forerunner  of  a  circumscribed  traumatic  aneurism  of  the  orbit,  attended 
by  pulsation,  bruit,  and  projection  of  the  e3’eball,  requiring  the  deligation 
of  the  common  carotid  for  its  cure. 

Bleeding  from  the  Nose  or  Mouth  may  of  course  arise  from  any  injury 
of  these  parts  without  the  skull  being  implicated  ;  3'et  in  some  cases  of 
fracture  of  the  skull  the  hemorrhage  proceeds  from  the  interior  of  the 
cranium,  through  a  fissure  in  the  roof  of  the  nasal  fossae;  it  then  indi¬ 
cates  a  fracture  though  the  ethmoid  and  sphenoid  bones.  In  a  patient 
of  mine  who  died  five  weeks  after  an  injury  of  the  head,  accompanied  by 
bleeding  from  the  nose,  a  fracture  by  contrecoup  was  found  extending 
across  one  orbital  plate  of  the  frontal  bone,  and  separating  its  articula¬ 
tion  with  the  ethmoid.  In  this  case,  the  nature  of  the  injury  was  sus¬ 
pected  from  the  fact  of  the  nose  itself  having  been  uninjured  b3'  the  blow, 
although  the  hemorrhage  from  it  was  veiy  considerable  and  continuous ; 
for  it  is  in  the  quantity  and  duration  of  this  hemorrhage  that  its  value 
as  a  diagnostic  sign  of  fracture  of  the  base  of  the  skull  consists. 

Vomiting  of  Blood  ma}^  occur  in  these  cases,  from  the  blood  finding 
its  way  through  the  fractured  ethmoid  or  sphenoid  down  the  nose  and 
through  the  posterior  nares  into  the  phaiynx  and  stomach.  In  these 
cases  the  vomited  blood  is  dark,  clotted,  and  mixed  with  the  contents  of 
the  stomach.  In  some  rare  cases,  the  blood  that  issues  from  the  nose 
and  mouth  passes  into  these  cavities  through  the  Eustachian  tube.  The 
petrous  portion  of  the  temporal  bone  is  fractured,  and  the  middle  ear 
opened ;  the  tympanum,  however,  being  unbroken,  no  bleeding  bj’^  the  ear 
ensues,  but  the  blood  escapes  into  the  phaiymx  through  the  Eustachian 
tube.  In  some  cases  there  ma}"  be  a  combination  of  these  different  signs. 
Thus,  in  a  patient  of  mine  at  the  Hospital,  there  were  hemorrhage  into 
the  left  orbit  and  from  the  left  nostril,  copious  vomiting  of  blood,  and 
bleeding  from  the  right  ear,  following  a  blow  upon  the  forehead.  The 
diagnosis  which  was  made  during  life,  and  which  w^as  verified  after  death, 
was  a  fissure  of  the  skull  extending  through  the  left  orbital  plate  of  the 
frontal  bone,  the  ethmoid,  and  probably  the  sphenoid  on  that  side,  and  a 
fracture  of  the  petrous  portion  of  the  right  temporal  bone. 

2.  The  Discharge  of  a  thin  Watery  Fluid  from  the  interior  of  the  skull 
sometimes  occurs ;  and,  when  it  happens,  it  is  the  most  certain  sign  of 
VOL.  I. — 30 


466 


INJURIES  OF  THE  HEAD. 


fracture  of  the  base  that  we  possess.  The  discharge  usually  takes  place 
through  the  ear ;  but  it  may  occur  from  the  nose,  of  which  I  have  seen 
one  instance,  and  Robert  mentions  another.  Still  more  rarely  it  takes 
place  from  a  wound  in  the  scalp  communicating  with  the  fracture;  per¬ 
colating  through  this,  and  so  being  poured  out  externally.  Cases  of  this 
kind  have  been  described  by  Hey,  O’Callaghan,  Robert,  Hewett,  and 
other  Surgeons.  One  such  instance  was  communicated  to  me  by  one  of 
the  pupils  of  University  College,  a  few  years  ago.  A  boy  received  a 
wound  on  the  back  of  the  head,  with  depressed  and  comminuted  frac¬ 
ture  of  the  skull.  On  the  nineteenth  day  after  the  receipt  of  the  injury, 
a  large  quantity  of  serous  fluid  began  to  escape  through  the  wound,  and 
continued  to  do  so  profusely  until  his  death  from  coma  four  days  later. 
At  first  the  fluid  that  is  discharged  is  usually  tinged  with  blood,  but  this 
soon  ceases,  and  it  then  flows  clear. 

There  would  consequently  appear  to  be  three  situations — the  ear,  the 
nose,  and  a  wound  on  the  vault  of  the  cranium — from  which  this  dis¬ 
charge  has  been  observed.  It  is  an  exceedingly  valuable  though  most 
serious  sign ;  and  Robert,  who  has  investigated  this  phenomenon  with 
much  closeness,  states  that  the  cases  in  which  it  happens  always  termi¬ 
nate  fatall3^  This,  however,  is  an  error ;  for  a  number  of  cases  have 
occurred  at  the  Universitj^  College  Hospital  and  elsewhere,  in  which  the 
patients,  adults,  recovered,  although  many  ounces  of  fluid  were  dis¬ 
charged  from  the  ear.  It  is  usually  associated  with  symptoms  indicative 
of  serious  injury  to  the  base  of  the  brain;  but  to  this  there  are  also 
exceptions,  for  I  have  seen  it  in  cases  of  injury  of  the  head,  unaccom¬ 
panied  by  any  severe  cerebral  symptoms.  Most  generally  it  occurs  in 
young  people.  Robert  says  that  it  does  so  invariably ;  but  Hewett  states 
that  in  most  of  the  instances  in  which  he  has  seen  it  the  patients  were 
above  thirty  years  of  age.  In  one  of  the  cases  that  I  have  witnessed,  the 
patient  was  fifty-eight  years  of  age ;  and  in  six  other  instances  in  which 
I  have  observed  it,  the  patients  were  all  adults.  In  all  cases  of  recovery 
that  I  have  witnessed,  some  deafness  of  the  ear  from  which  the  discharge 
occurred  has  been  left ;  but  the  hearing,  though  usually  lost,  does  not 
always  appear  to  be  destroyed  in  the  ear  from  which  the  discharge  takes 
place. 

The  Quantity  of  fluid  that  is  thus  discharged  is  always  very  consider¬ 
able,  the  pillow  usually  becoming  soaked  by  it,  and  thus  first  attracting 
attention  to  it.  It  is  often  necessary  to  keep  a  piece  of  sponge  or  a 
pledget  of  lint  against  the  ear,  in  order  to  prevent  the  fluid  from  wetting 
the  patient  as  it  trickles  out ;  and,  if  a  cup  be  so  placed  as  to  collect 
it,  an  ounce  or  two  will  speedily  accumulate.  Laugier  states  that  he 
has  seen  a  tumblerful  discharged  in  a  short  time,  and  as  much  as  twenty 
ounces  have  been  known  to  be  poured  out  in  three  days.  The  flow  is 
usually  continuous  for  several  days,  and  then  ceases. 

Although  the  occurrence  of  a  wateiy  discharge  from  the  ear  after  cer¬ 
tain  injuries  of  the  head  had  been  observed  by  Van  der  Wiel,  O’Halloran, 
and  Hease,  in  the  early  part  and  middle  of  the  last  century,  no  attention 
was  paid  to  the  subject  by  later  surgical  writers;  and  the  subject  appears 
to  have  been  completely  lost  sight  of  until  Laugier,  in  1839,  again 
directed  the  attention  of  Surgeons  to  this  interesting  phenomenon. 
Since  this  period,  it  has  been  often  observed  and  attentively  studied ; 
and  the  nature  and  the  source  of  this  discharge  have  been  particularly 
investigated  by  Laugier,  Chassaignac,  Robert,  Guthrie,  and  Hewett.  Its 
physical  and  chemical  characters  are  those  of  a  perfectly  clear,  limpid, 
and  watery  fluid,  containing  a  considerable  quantity  of  chloride  of  sodium. 


SEROUS  DISCHARGE  FROM  SKULL. 


467 


with  a  little  albumen  in  solution,  and  some  sugar.  It  is  not  coagulable 
by  heat  nor  by  nitric  acid. 

The  Source  of  this  discharge  has  been  the  subject  of  much  speculation. 
Laugier  believed  it  to  be  the  serum  of  the  blood  filtered  through  a  crack 
in  the  petrous  portion  of  the  temporal  bone,  and  so  through  the  rup¬ 
tured  tympanum.  This  explanation,  however,  is  evidently  not  correct ; 
for  not  only  is  blood  extravasated  in  the  living  body  incapable  of  this 
species  of  rapid  and  complete  filtration,  but  the  fluid  diflers  altogether 
in  chemical  composition  from  the  serum  of  the  blood,  in  containing  a 
mere  trace  of  albumen  and  double  the  quantity  of  chloride  of  sodium. 
By  others  it  has  been  supposed  that  the  fluid  is  furnished  by  the  inter¬ 
nal  ear,  being  a  continuous  discharge  of  the  liquor  Cotunnii ;  but  its 
large  quantit3^,  and,  above  all,  the  fact  of  its  occasionally  escaping 
through  the  nose,  establish  the  fallacy  of  this  explanation.  Again,  it 
has  been  supposed,  but  without  suflScient  evidence,  that  the  cavity  of 
the  arachnoid  furnishes  this  secretion.  But  the  arachnoid  does  not 
secrete  suflScientl}’’  to  furnish  the  quantit}’’  of  fluid  discharged ;  and  if 
this  membrane  were  irritated  and  the  secretion  increased,  it  would  be¬ 
come  opaque  from  l^^mph  or  pus  admixed  with  it.  Others  have  looked 
upon  it  as  the  saliva  flowing  back  through  the  Eustachian  tube,  and  thus 
entering  the  ear,  and  draining  out  through  the  ruptured  tjunpanum  ;  but 
the  fluid  differs  so  complete!}"  from  saliva  as  to  render  this  supposition 
untenable.  I  think,  with  Kobert,  that  there  can  be  little  doubt  that  this 
discharge,  in  most  cases  at  least,  consists  of  the  cerebro-spinal  fluid ; 
for  not  only  is  it,  in  appearance  and  chemical  composition,  identical  with 
this  liquid,  but  there  is  no  other  source  within  the  skull  than  the  pia 
mater  which  can  yield  with  equal  rapidity  so  large  a  quantity  of  fluid ; 
experiment  on  animals  having  shown  that  the  cerebro-spinal  fluid  is 
rapidly  reproduced  after  its  evacuation.  An  additional  point  of  analogy 
between  this  discharge  and  the  cerebro-spinal  fluid  is  to  be  found  in  the 
fact  pointed  out  b}"  C.  Bernard,  that  they  both  contain  a  small  quantity" 
of  sugar.  In  order  that  the  fluid  be  discharged,  the  membranes  of  the 
brain  must  have  been  torn  opposite  the  outlet  by  which  it  poured  forth. 
This  has  actuall}"  been  ascertained  to  be  the  case,  by  carefully  conducted 
dissections.  When  it  is  discharged  through  the  ear,  the  laceration,  as 
Berard  has  remarked,  must  have  extended  through  the  cul-de-sac  of  the 
arachnoid,  which  is  prolonged  around  the  auditoiy  nerve  in  the  internal 
auditor}"  canal.  When  it  is  poured  out  through  the  nose,  the  fracture 
has  probably  extended  through  the  cribriform  plate  of  the  ethmoid  bone, 
and  laid  open  the  prolongation  of  arachnoid  that  surrounds  the  filaments 
of  the  olfactory  nerve. 

The  diagnostic  value  of  watery  discharge  from  the  ear  varies,  accord¬ 
ing  to  Hewett,  with  its  relation  to  the  hemorrhage  which  may  occur. 
He  divides  cases  of  watery  discharge  from  the  ear  after  injuries  of  the 
head  into  three  classes. 

In  the  first  class,  the  discharge  is  watery  from  the  first,  and  abundant, 
being  preceded  by  little  or  no  blood,  and  beginning  immediately  after 
the  accident.  This  is  undoubtedly  cerebro-spinal  fluid,  which  escapes 
through  a  fracture  of  the  petrous  bone  implicating  the  internal  auditory 
canal. 

In  the  second  class,  there  is  copious  and  prolonged  bleeding  from 
the  ear,  followed  by  the  watery  discharge.  Here,  too,  there  is  fracture 
of  the  petrous  bone ;  but  its  exact  situation  is  uncertain.  In  these 
cases,  the  diagnosis  will  rest  upon  the  prolonged  hemorrhage,  rather 
than  on  the  watery  discharge. 


468 


INJURIES  OF  THE  HEAD. 


In  the  third  class,  there  is  but  little  bleeding  after  the  injury,  and  the 
watery  discharge,  which  is  variable  in  quantity,  varies  also  in  the  time 
of  its  appearance.  In  these  cases  the  diagnosis  must  remain  doubtful. 
He  mentions  two  cases  which  occurred  at  St.  George’s  Hospital  in  which 
a  copious  watery  discharge  flowed  from  the  ear.  In  neither  of  these 
after  death  was  any  fracture  of  the  petrous  portion  of  the  temporal 
bone  found.  In  one  the  membrana  t3’mpani  was  ruptured,  and  the  cavity’’ 
of  the  tj^mpanum  was  “intensely"  vascular;”  in  the  other,  “  the  discharge 
was  connected  with  a  fracture  of  the  lower  jaw  just  below  the  cond^de: 
the  lower  fragment  had  perforated  the  wall  of  the  meatus  auditorius.” 

Treatment. — The  treatment  of  fracture  of  the  base  of  the  skull  must 
be  conducted  on  those  general  principles  that  guide  us  in  the  manage¬ 
ment  of  simple  fractures  ;  no  special  means  can  be  had  recourse  to,  and 
in  veiy  man}^  cases  a  fatal  termination  speedil}’^  ensues. 

Depressed  Fracture  of  the  Skull. — It  occasionally  though  very 
rarely  happens  that,  in  consequence  of  a  blow,  a  portion  of  the  skull  is 
depressed  without  being  fractured,  and  even  without  aiy^  serious  cere¬ 
bral  S3’mptoms  occurring.  Such  depression  without  fracture  can,  how¬ 
ever,  onl3^  occur  in  children,  whose  skulls  are  soft  and  3delding.  In 
adults  it  cannot  happen  without  the  occurrence  of  partial  or  incomplete 
fracture.  Maiy^,  if  not  all,  of  the  so-called  “congenital  depressions” 
that  are  met  with  in  the  skull  are  the  result  either  of  violence  inflicted 
on  the  cranium  at  birth,  usually  in  instrumental  labors,  or  of  falls  and 
blows  upon  the  head  in  early  infancy.  Such  depressions  are  smooth, 
concave,  and  sometimes  symmetrical,  and  present  veiy  different  charac¬ 
ters  from  the  irregular  outline  of  an  ordinary  fracture.  They  never 
present  the  characters  of  a  fissure;  there  is  no  such  thing  as  a  congeni¬ 
tal  fissure  of  the  skull. 

In  the  Diagnosis  of  depressed  fracture,  it  is  important  to  remember 
that  the  apparent  depression  produced  hy  an  extravasation  under  the 
scalp  may  simulate  this  injury  very  closely ;  for  even  an  experienced 
Surgeon  ma3’'  sometimes  in  these  circumstances  be  induced  to  cut  down 
on  a  suspected  fracture,  when  in  realit3^  none  exists.  This  happens  in 
■consequence  of  the  blood  that  is  extravasated  coagulating  round  the 
circumference  of  the  contusion,  whilst  that  which  is  in  the  centre  remains 
fluid,  so  that  a  veiy  deceptive  sensation  of  a  hollow  with  a  hard  rim  is 
communicated  to  the  finger. 

Varieties. — Depressed  fractures  of  the  skull  may  either  be  simple, 
without  wound  of  the  scalp ;  compound ;  or  comminuted.  In  the  ma¬ 
jority  of  cases,  whether  the  fracture  be  simple  or  compound,  there  is 
comminution  of  the  bone ;  the  fragments  being  perhaps  driven  into  the 
brain. 

Sometimes,  though  veiy  rarely,  the  external  table  alone  is  depressed 
and  driven  into  the  diploe.  This  is  especiall3'  the  case  over  the  frontal 
sinuses,  where  it  ma3'  be  broken  in,  as  I  have  seen  happen  from  the  kick 
of  a  horse,  without  the  inner  table  being  splintered,  or  any  bad  conse¬ 
quence  ensuing. 

The  inner  table  ma3^  be  fractured  without  an3"  injuiy  whatever  to  the 
outer  table ;  and  it  ma3^  not  onl3"  be  so  fractured,  but  a  portion  of  it 
ma3^  be  depressed,  without  the  outer  table  being  injured.  Of  this 
remarkable  injuiy  several  cases  are  recorded  as  having  happened  in  the 
late  American  war,  and  are  figured  in  the  Official  Surgical  Report. 
More  commonl3q  when  the  inner  table  is  thus  fractured  or  depressed, 
the  outer  table  is  fissured.  In  all  ordinary  depressed  fractures,  the 
internal  table  is  splintered  to  a  greater  extent  than  the  external  one. 


DEPRESSED  FRACTURE  OF  THE  SKULL. 


469 


This  is  especially  the  case  when  the  fracture  is  the  result  of  gunshot 
injuiy,  or  when  it  has  been  occasioned  by  blows  with  a  pointed  weapon, 
as  the  end  of  a  pick,  or  a  large  nail,  or  the  sharp  angle  of  a  brick.  In 
these  fractures,  which  constitute  the  dangerous  variety  termed  Punctured,, 
the  outer  table  may  be  merely  perforated  or  fissured,  whilst  the  inner 
one  is  widely  splintered  into  numerous  fragments,  for  the  extent  of  a 
square  inch  or  more.  This  splintering  of  the  inner  lamina  of  the  skull 
to  a  greater  extent  than  the  outer  one  has  attracted  much  attention, 
being  of  considerable  practical  moment,  and  is  usually  said  to  be  owing 
to  its  being  more  brittle  than  the  external  table.  This,  however,  I  do 
not  consider  to  be  the  only  cause.  I  should  rather  attribute  it  to  the 
fracturing  force  from  without  inwards  losing  a  certain  amount  of  mo¬ 
mentum  in  passing  through  the  outer  table;  the  inner  table  being  thus 
splintered  more  widely  than  the  outer  one,  for  the  same  reason  that  the 
aperture  of  exit  made  by  a  bullet  is  larger  than  that  of  entry.  If  this 
be  the  true  explanation,  the  reverse  ought  to  hold  good  if  the  force  be 
applied  in  the  opposite  direction.  It  is  very  seldom  that  we  have  an 
opportunity  of  examining  such  a  case  ;  but,  some  years  ago,  a  man  was 
brought  to  the  Hospital  who  had  discharged  a  pistol  into  his  mouth  and 
upwards  through  the  brain.  The  bullet  had  perforated  the  palate  and 
passed  out  at  the  upper  part  of  the  cranium,  near  the  vertex.  On 
examining  the  state  of  the  bones,  it  was  found  that  the  outer  table  of 
the  skull  was  splintered  to  a  considerably  greater  extent  than  the  inner 
one,  showing  clearly  the  influence  of  the  direction  of  the  fracturing  force 


Fig.  199. 


Fracture  of  the  Skull  from  Gunshot  Injury  from 
within:  Splintering  of  Outer  Table. 


Fig.  200. 


The  same — natural  size. 


(Figs.  199,  200).  This  case  led  me  to  make  further  experiments  on  the 
dead  body ;  and  I  found  that  the  outer  table  is  always  more  splintered 
when  the  blow  is  struck  from  the  inside  of  the  skull  outwards. 

Teevan  has  made  a  considerable  number  of  ingenious  experiments  on 
this  subject,  b}’’  firing  bullets  and  driving  pointed  bodies  of  various  kinds 
through  the  skull.  He  finds,  as  the  result  of  these  investigations,  that 
the  aperture  of  exit  is  the  larger,  whether  the  blow  be  delivered  or  the 
bullet  be  driven  from  without  inwards,  or  the  reverse.  The  explanation 
at  which  he  has  arrived  is,  that  the  aperture  of  entry  is  caused  bj'  the 
penetrating  body  only,  whilst  the  aperture  of  exit  is  caused  by  this  plus 
the  fragments  of  bone  driven  out  of  that  table  of  the  skull  which  was 
first  perforated.  Thus,  when  a  bullet  strikes  the  external  table  from 


470 


INJURIES  OF  THE  HEAD. 


without,  it  first  perforates  this,  and  then  carries  along  with  it  and  through 
the  inner  table  the  fragments  of  bone  that  it  has  cut  out  of  the  external 
table,  and  hence  fractures  the  inner  table  more  widely  than  the  outer. 
When  both  sides  of  the  head  are  traversed  b}^  a  bullet,  it  will  be  found 
that  the  aperture  of  entry  in  the  outer  table  on  the  side  first  struck,  and 
the  aperture  of  entry  in  the  inner  table  of  the  opposite  side  of  the  head,  will 
be  the  smallest,  the  largest  holes  made  by  the  bullet  being  the  apertures 
on  the  inner  table  of  the  former  side  and  the  outer  table  of  the  latter. 
In  the  case  of  a  large  and  broad  bodj^  like  a  bullet,  which  carries  and 
does  not  merely  j^erforate  bone,  Teevan’s  explanation  is  doubtless  cor¬ 
rect.  But,  in  the  ordinary  “  punctured”  fracture,  made,  for  instance,  by 
the  point  of  a  nail  being  driven  through  the  skull,  it  must  be  remembered 
that  no  fragments  of  the  outer  table  or  diploe  are  carried  onwards,  and 
that  the  very  wide-spread  splintering  of  the  inner  table,  which  is  cha¬ 
racteristic  of  this  form  of  injuiy,  cannot  be  accounted  for  in  this  way, 
but  appears  to  me  to  be  referable  to  the  cause  I  have  given,  viz.,  the 
direction  of  the  fracturing  force  and  the  loss  of  momentum  in  the  break¬ 
ing  body. 

It  occasionally  happens,  as  the  result  of  sabre  or  hatchet-cuts  on  the 
head,  that  a  kind  of  longitudinal  punctured  fracture  occurs,  in  which  the 
outer  table  is  merely  notched,  whilst  the  inner  one  is  splintered  along 
the  whole  line  of  blow.  In  other  cases,  again,  a  portion  of  the  skull  is 
completely  sliced  off,  hanging  down  in  a  flap  of  the  scalp,  and  exposing 
the  brain  or  its  membranes. 

A  special  and  very  important  kind  of  punctured  and  depressed  frac¬ 
ture  is  that  in  which,  by  the  thrust  of  a  stick,  umbrella,  or  other  blunt- 
ended  body  into  the  orbit,  the  orbital  plate  of  the  frontal  bone,  or  the 
cribriform  lamella  of  the  ethmoid,  is  perforated,  and  the  dura  mater  or 
brain  wounded.  In  such  cases  there  is  sometimes  no  external  wound 
even,  the  stick  having  passed  up  under  the  upper  eyelid  ;  and  it  is  con¬ 
ceivable  that  the  same  result  might  even  be  produced  by  a  thrust  up  the 
nostril.  Death  results  either  from  wound  of  the  cavernous  sinus  and 
intracranial  extravasation  of  the  blood,  or  more  remotely  from  the 
secondary  inflammatory  effects  of  the  wound  of  the  dura  mater  and 
brain. 

The  Symptoms  of  a  depressed  fracture  of  the  skull  are  of -two  kinds: 
those  that  are  dependent  upon  the  injury  to  the  bone,  and  those  that 
result  from  the  concomitant  compression  or  laceration  of  the  brain. 

When  the  scalp  is  not  wounded,  the  depression  may  sometimes  be  felt ; 
but  very  commonly  it  is  marked  by  extravasation  of  blood  about  it,  and 
the  Surgeon  is  only  led  to  suspect  its  existence  by  the  continuance  of 
symptoms  of  compression  from  the  time  of  the  injury.  In  all  cases  of 
doubt, >when  these  symptoms  exist,  an  incision  should  be  made  through 
the  scalp  at  the  seat  of  injury,  and  the  state  of  the  skull  examined. 
When  there  is  a  wound  in  the  scalp  communicating  with  the  fracture, 
the  Surgeon  detects  at  once  the  existence  of  depression  and  comminution 
by  examining  the  bone  with  his  finger  through  the  wound.  When  the  frag¬ 
ments  that  are  depressed  are  impacted  and  firml}’'  locked  together,  so  as  to 
form  an  unyielding  mass,  s3"mptoms  of  compression  of  the  brain,  to  a  more 
or  less  marked  degree,  usually  result.  But  if  the  fracture  be  very  ex¬ 
tensive,  and  the  fragments,  though  somewhat  depressed,  lie  loose,  and  if 
they  be  yielding  and  do  not  exercise  a  continuous  pressure  on  the  brain, 
it  occasionall3’' happens  that  no  cerebral  disturbance  comes  on  for  some 
da^'s,  even  though  the  injury  be  veiy  extensive.  A  man  twenty-four 
years  of  age  was  admitted  into  University  College  Hospital.  He  had 


TREATMENT  OF  DEPRESSED  FRACTURE. 


471 


been  struck  on  the  forehead  with  the  sharp  edge  of  a  quoit.  The  frontal 
bone  was  extensively  comminuted,  twelve  fragments  being  removed,  and 
the  dura  mater  being  exposed  to  a  considerable  extent;  yet  no  bad 
symptoms  occurred  until  the  ninth  day,  when  inflammation  of  the  brain 
and  its  membranes  set  in,  and  he  speedily  died. 

In  other  cases  again,  more  especially  in  children  and  young  persons, 
in  whom  the  bones  are  soft  and  yielding,  fracture  with  depression  may 
exist  to  a  considerable  extent,  and  no  symptom  whatever  of  compression 
be  produced  at  any  time,  the  patient  living  with  a  portion  of  his  skull 
permanently  beaten  in.  I  have  several  times  seen  persons  in  after-life 
with  large  flat  depressions  of  the  skull,  the  result  of  injuries  sustained 
in  childhood,  who  presented  no  signs  of  cerebral  disturbance.  It  is  very 
rare,  however,  to  meet  with  a  recent  case  of  depressed  fracture  in  the 
adult  without  signs  of  compression  of  the  brain.  But,  though  rare,  it  is 
not  impossible;  and  Green  mentions  the  case  of  a  man  whose  skull  was 
depressed  to  the  extent  of  the  bowl  of  a  dessertspoon,  without  any 
symptoms  of  compression. 

Wounds  of  the  Dura  Mater. — The  great  danger  in  these  cases  of  de¬ 
pressed  and  comminuted  fracture  arises  not  only  from  the  compression 
of  the  brain,  but  from  the  rapidity  with  which  inflammation  is  set  up  in 
consequence  of  the  sharp  fragments  wounding  and  irritating  the  mem¬ 
branes  and  brain.  Indeed,  a  wound  of  the  dura  mater,  however  slight, 
is  a  most  dangerous  complication.  This  is  more  especially  the  case  in 
those  injuries  in  which  the  inner  table  is  extensively  splintered,  as  in 
the  different  forms  of  punctured  fracture.  In  these  cases  there  may  be 
no  signs  of  compression ;  but  inflammation  speedily  sets  in,  and  cer¬ 
tainly  proves  fatal  if  the  cause  of  irritation,  the  sharp  spicula,  be  allowed 
to  remain  in  contact  with  the  dura  mater.  This  membrane  becomes 
sloughy,  and  coated  with  a  thick  deposit  of  plastic  matter,  whilst  the 
usual  evidences  of  encephalitis  are  found  in  the  other  membranes  and 
the  brain.  Wounds  of  the  dura  mater,  though  in  the  highest  degree 
dangerous,  are  not  necessarily  fatal.  In  military  practice  it  has  often 
happened  that,  as  the  result  of  sabre-cuts,  portions  of  the  skull  have 
been  sliced  or  split  down,  the  subjacent  membranes  and  the  brain  itself 
being  wounded,  and  yet  a  good  recovery  has  resulted  ;  and  I  have  had 
several  cases  under  my  own  care  in  which,  though  the  dura  mater  has 
been  punctured  by  spicula  of  depressed  fractures,  and  portions  of  brain 
lost,  the  patients  have  made  a  good  recovery. 

The  Treatment  of  a  depressed  and  comminuted  fracture  of  the  skull 
varies  not  only  according  to  the  nature  and  extent  of  the  accident,  but 
also  to  the  existence  or  absence  of  symptoms  of  compression  of  the  brain. 

If  there  be  no  wound  in  the  scalp,  but  the  occurrence  of  symptoms  of 
compression  and  the  existence  of  some  irregularity  of  the  skull  at  the 
seat  of  injury  lead  the  Surgeon  to  suspect  a  depressed  fracture,  he  should 
make  a  crucial  or  T-shaped  incision  down  upon  the  part  in  order  to 
examine  the  bone  ;  and,  if  this  be  found  depressed,  he  should  elevate  or 
remove  it. 

If  the  scalp  be  already  wounded,  all  that  need  be  done  to  ascertain 
the  nature  of  the  fracture,  is  to  pass  the  finger  very  gently  into  the 
wound  and  thus  examine  the  bone.  If  any  fragments  be  found  lying 
loose,  they  should  be  picked  out,  as  they  can  only  excite  injurious  irrita¬ 
tion  ;  any  bone  that  is  driven  below  its  level  must  be  raised,  and,  if 
completely  detached,  removed. 

In  order  to  raise  these  depressed  portions  of  bone,  it  is  in  many  cases 
only  necessary  to  introduce  the  point  of  an  elevator  underneath  the 


472 


INJURIES  OF  THE  HEAD. 


fragment,  and,  using  the  instrument  as  a  lever,  raise  it  into  position. 
If  there  be  not  an  aperture  sufficiently  large  for  the  introduction  of  the 
elevator,  one  may  be  made  by  sawing  out  an  angle  of  bone  at  a  conve¬ 
nient  spot  b}^  means  of  a  Hey’s  saw^,  or  clipping  off  a  projecting  point 
with  the  bone  forceps.  In  this  way,  sufficient  space  may  usually  be 
gained  without  the  necessity  of  applying  the  trephine.  If,  however,  the 
inner  table  be  splintered  to  a  considerable  extent,  or  if  there  be  no  con¬ 
venient  angle  that  can  be  removed,  the  trephine  must  be  applied  in  such 
a. way  that  at  least  half  its  circle  is  situated  upon  the  edge  that  over¬ 
hangs  the  depressed  bone ;  the  Surgeon  sawing  out  by  means  of  this 
instrument  a  portion  of  the  undepressed  skull,  in  order  that  he  may  more 
conveniently  get  at  the  fragment.  After  a  half  circle  of  bone  has  been 
removed  in  this  way,  the  depressed  splinters  may  be  taken  out,  a  Hey’s 
saw  still  being  occasionally  required  before  the  whole  can  be  removed ; 
the  flaps  of  scalp  should  then  be  laid  down,  a  suture  or  two  applied,  and 
water-dressing  put  over  the  wound.  Rigorous  treatment  must  then  be 
adopted,  with  the  view  of  preventing  or  removing  inflammatory  symptoms. 

In  all  cases  of  Punctured  Fracture^  where  there  is  but  slight  injury 
of  the  external  table,  with  considerable  splintering  and  depression  of  the 
inner  one,  or  where  there  is  a  narrow  and  deep  depression  of  the  bone, 
the  trephine  must  be  applied  on  different  principles  from  those  that  guide 
us  in  its  use  in  ordinary  depressed  fractures.  In  the  punctured  fracture 
it  is  applied,  not  to  remove  symptoms  of  compression  which,  in  all  pro- 
babilit}",  may  not  exist ;  but  with  the  view  of  preventing  the  inflamma¬ 
tion  which  will  to  a  certainty  be  set  up  if  the  splinters  of  the  inner  table 
be  allowed  to  continue  irritating  the  membranes  and  brain.  Hence  it  is 
a  rule  in  surgery,  in  all  cases  of  punctured  fracture,  to  apply  the  trephine 
at  once.  In  these  cases  a  trephine  with  a  large  crown  should  be  used, 
and  the  circle  of  injured  bone  itself  must  be  sawn  out.  Should,  how¬ 
ever,  the  use  of  the  trephine  have  been  delayed  in  these  cases  until  inflam¬ 
matory  action  has  been  set  up,  the  instrument  may  still  be  applied  with 
advantage.  Many  jmars  ago  a  boy  was  admitted  into  University  College 
Hospital,  on  the  sixteenth  day  after  having  been  struck  on  the  side  of 
the  head  by  a  large  nail,  wdiich  projected  from  a  door  that  fell  upon  him. 
No  s3"mptoms  of  aii}^  kind  had  occurred  until  the  eleventh  daj'  after  the 
accident,  when  he  became  dull  and  lost  his  appetite ;  on  the  sixteenth 
da}’,  that  of  his  admission,  he  had  suddenly  become  drowsy  and  delirious, 
but  answered  rationally  when  spoken  to,  and  complained  of  pain  in  the 
head.  The  pupils  were  dilated,  the  skin  hot,  and  the  pulse  quick.  On 
examination  a  small  round  aperture,  from  which  some  fetid  pus  exuded, 
was  discovered  on  the  right  parietal  eminence.  On  introducing  a  probe, 
which  the  hole  just  admitted,  some  rough  bone  could  be  felt.  S.  Cooper 
immediately  trephined  the  boy,  removing  a  circle  of  bone  including  the 
small  aperture.  The  inner  table  corresponding  to  this  was  found  splin¬ 
tered  to  some  extent,  and  the  dura  mater  w’as  thickened  and  inflamed ; 
but  the  patient  recovered  without  a  bad  symptom. 

In  those  rare  cases  in  w’hich  there  is  a  Dei^ressed  Fracture^  without 
symptoms  of  compression  or  even  a  wound  of  the  scalp,  the  rule  of 
practice  is  somewhat  unsettled,  as  to  whether  the  depressed  portion  of 
bone  should  be  left  where  it  is,  or  an  attempt  be  made  to  elevate  it.  Sir 
A.  Cooper,  Abernethy,  and  Hupuytren  advise  that,  if  it  do  not  give  rise 
to  any  symptoms  of  compression,  it  is  better  not  to  interfere  with  it  ; 
and  there  are  several  cases  on  record  of  patients  who  have  recovered  in 
whom  this  course  was  adopted,  the  depression  continuing  permanent. 
That  non-interference  is  the  proper  course  to  pursue  in  some  cases,  more 


TREATMENT  OF  DEPRESSED  FRACTURE. 


473 


particularly  in  children,  there  can  be  no  doubt.  I  have  had  under  ni}^ 
care  a  child  in  whom,  in  consequence  of  a  fall,  there  was  on  one  of  the 
parietal  bones  a  depression  as  large  as  a  crown-piece,  its  edges  being 
sharply  defined :  no  signs  of  compression  or  of  inflammation  of  the  brain 
ensued,  and  it  was  consequently  left  without  interference,  the  child 
making  an  excellent  recovery,  and  continuing  well.  Indeed,  in  children, 
the  ambunt  of  injury  that  maybe  inflicted  on  the  brain  not  only  by  com¬ 
pression  but  by  actual  laceration,  and  yet  be  followed  by  recoveiy,  is 
very  surprising. 

In  the  adult,  the  cerebral  substance  does  not  accommodate  itself  so 
readily  to  injuries,  and  here  the  line  of  practice  is  not  quite  so  definite. 
But  even  in  persons  of  mature  age,  under  certain  favorable  circumstances, 
bone  ma}"  be  depressed  and  continue  so  without  giving  rise  either  to 
compression  of  the  brain  or  to  inflammation  of  its  membranes.  I  had 
once  under  my  care  a  case  which  illustrated  this  point  forcibly.  The 
patient,  a  middle-aged  man,  fell  on  his  head  into  an  area,  and  stripped 
off  the  greater  part  of  the  scalp  from  the  anterior  part  of  the  head  and 
the  vertex ;  on  the  upper  part  of  the  left  parietal  bone  was  a  starred 
and  depressed  fracture  of  the  skull  as  large  as  a  florin.  As  the  depres¬ 
sion  w'as  smooth,  not  more  than  a  quarter  of  an  inch  in  depth,  and  there 
was  no  symptom  of  compression,  I  drew  the  scalp  forwards  and  left  the 
bone  untouched,  the  patient  making  an  excellent  recoveiy,  without  any 
symptom  of  intracranial  mischief.  I  am  also  acquainted  with  a  gentle¬ 
man  upwards  of  fift}^  3'ears  of  age,  w’ho  has  a  depression  in  the  parietal 
bone  as  large  as  the  bowl  of  a  tablespoon,  the  result  of  a  fracture  b^’’ 
a  fall  from  a  horse  when  a  lad,  and  from  which  no  inconvenience  has 
resulted.  I  think,  however,  that  this  expectant  practice  should  not  be 
followed  too  implicitl}^,  but  that  w^e  must  be  guided  by  the  circumstances 
of  the  particular  case.  If  the  depression  be  nearl}”  uniform,  of  incon¬ 
siderable  depth,  and  occupy  some  extent  of  skull,  which  is  depressed  in 
a  smooth  hollow  or  bowl-like  manner,  and  more  especialh’’  if  the  patient 
be  3’oung  and  the  scalp  unwounded,  it  ma3^be  better  doubtless  to  follow 
the  advice  of  Cooper,  Aberneth3^,  and  Dupuytren,  and  to  wait  for  S3mip- 
toms  of  compression  manifesting  themselves  before  we  interfere.  If, 
however,  the  scalp  be  wounded,  the  depression  be  sharp,  deep,  and  com¬ 
paratively  small  in  extent,  we  ma3’'  reasonably  suspect  the  existence  of 
considerable  splintering  of  the  inner  table  ;  and  here,  I  think,  the  safer 
plan  would  be,  even  in  the  absence  of  all  S3'mptoms  of  compression,  to 
elevate  for  the  same  reason  that  we  trephine  in  punctured  fracture — the 
prevention  of  inflammatory  action  that  will  be  occasioned  by  the  irrita¬ 
tion  of  the  splinters  of  the  inner  table.  I  would  not,  however,  venture 
to  dogmatize  on  this  very  important  and  difficult  point  of  practice.  The 
opinions  of  the  most  experienced  Surgeons  are  at  variance ;  and  cases 
may  readily  be  adduced  on  either  side  in  support  of  conflicting  doctrines. 
It  would  appear  that  military  Surgeons  generally  are  in  favor  of  the 
expectant  plan,  and  cases  ma3^  be  found  in  the  works  of  Guthrie,  Ballin- 
gall,  etc.,  in  support  of  this  practice ;  and  it  is  a  remarkable  circum¬ 
stance  that,  in  man3’  of  these  instances  in  which  recoveiy  resulted  in 
cases  of  depressed  fracture  of  the  skull  which  were  not  subjected  to 
operative  interference,  the  patients  were  exposed  to  great  privation, 
possibl3'’  during  a  hurried  retreat,  and  left  in  circumstances  apparently 
the  least  favorable  to  recoveiy.  So  far  as  my  own  experience  is  con¬ 
cerned,  which  is  necessaril3"  drawn  purel3''  from  civil  practice,  I  can  say 
that,  with  the  exception  of  the  case  that  has  just  been  referred  to,  I  do 
not  recollect  ever  having  seen  a  case  recover  in  which  a  compound  de- 


474 


INJURIES  OF  THE  HEAD. 


pressed  fracture  of  the  skull  occurring  in  the  adult  had  been  left  without 
operation ;  but  I  have,  on  the  other  hand,  seen  several  instances  of 
recovery  in  which  the  bone  had  been  elevated  and  fragments  removed. 

The  sooner  this  is  done  the  better.  Danger  does  not  arise  from  early 
operation,  but  from  delaj’’.  The  presence  of  depressed  and  spiculated 
fragments  pressing  into  the  dura  mater  must  infallibly  and  speedily 
induce  encephalitis.  I  have  several  times  trephined  in  such  'circum¬ 
stances  as  these  with  success,  and  have  never  had  occasion  to  regret 
doing  so.  Indeed,  there  is  no  class  of  cases  in  which  the  operation 
of  trephining  is  attended  by  such  successful  results  as  in  those  of 
depressed  and  comminuted  fracture.  Even  though  several  da3’^s  have 
elapsed  and  inflammation  has  set  in,  the  proper  treatment  will  be  to 
remove  the  depressed  and  splintered  bone,  and  thus  give  the  patient  his 
Old}"  chance — a  slender  one,  it  is  true,  of  recoveiy.  In  such  adverse 
circumstances  the  patient  ma}’',  however,  be  saved.  A  man  was  ad¬ 
mitted  under  Liston  with  a  long  depressed  fracture  on  the  side  of  the 
head,  produced  by  the  blow  of  a  brickbat ;  though  no  sign  of  compres¬ 
sion  existed,  3’et  S3"mptoms  of  cerebral  inflammation  were  speedily  set 
up,  and  Liston  trephined  him  on  the  fourth  da3"  after  the  accident ;  the 
man,  who  was  perfectl3"  conscious,  walking  into  the  operating  theatre. 
A  considerable  splintering  of  the  inner  table  was  found,  the  fragments 
of  which  were  removed.  The  dura  mater  having  been  punctured  by  one 
of  the  spicula  of  bone,  diffuse  suppuration  of  the  membranes  of  the  brain 
set  in,  and  the  patient  died  in  a  few  days.  In  this  case,  however,  the 
necessity  for  earl3'  trephining  was  clearly  indicated,  notwithstanding 
the  absence  of  any  s3^mptom  of  compression. 

When  a  depressed  fracture  of  the  skull  is  complicated  with  a  fracture 
or  other  injury  of  the  spinal  column^  it  is  sometimes  difficult  to  deter¬ 
mine  how  much  of  the  symptoms  ma3"  be  due  to  one  accident,  and  what 
proportion  to  the  other.  In  such  a  case  as  this,  however,  we  should,  I 
think,  treat  the  depressed  fracture  irrespectively  of  the  vertebral  injury, 
thus  giving  the  patient  a  chance  of  recovery,  of  prolongation  of  life,  or, 
at  least,  a  return  of  consciousness  before  death.  A  man  was  admitted 
under  my  care  into  the  Hospital,  with  depressed  fracture  of  the  left 
parietal  bone,  and  injury  of  the  cervical  spine,  the  precise  nature  of 
which  could  not  be  accurately  determined.  He  was  in  a  state  of  com¬ 
plete  coma  and  paral3"sis.  I  trephined  the  skull  and  elevated  the 
depressed  portion  of  bone;  he  recovered  his  consciousness  to  a  great 
degree,  but  died  in  a  few  da3^s  apparently  from  the  injury  to  the  spine. 
On  examination  after  death  we  found  a  fracture  of  the  flfth  cervical 
vertebra. 


INJURIES  OF  THE  CONTENTS  OF  THE  CRANIUM. 

Wounds  of  the  Brain  and  its  Membranes  are  frequent  in 
injuries  of  the  head,  and  are  among  the  most  important  complications 
of  these  accidents.  The  extent  of  injury  inflicted  upon  the  cerebral 
substance  has  wide  limits,  from  slight  laceration  without  exposure,  to 
denudation  of  the  brain,  disintegration  and  escape  of  large  portions  of 
its  pulp. 

Causes. — Injury  to  the  brain  may  be  occasioned  in  various  wa3^s. 
The  simplest  form  is  that,  perhaps,  which  is  not  unfrequentl3’’  met  with 
in  undepressed  fracture  of  the  skull,  and  sometimes  happens  without 
fracture,  from  simple  concussion  or  commotion  of  the  head ;  laceration 
of  the  cerebral  substance  occurring  under  the  seat  of  injuiy,  or  more 


WOUNDS  OF  THE  BRAIN. 


475 


frequently  at  a  distant  or  opposite  point,  by  a  kind  of  contrecoup. 
This  laceration  of  the  brain  by  contrecoup  is  by  no  means  of  unfrequent 
occurrence.  I  have  seen  many  striking  instances  of  it,  and  have  found 
it  to  be  one  of  the  commonest  causes  of  death  in  simple  fracture  of  the 
skull.  Laceration  of  the  brain  by  contrecoup  is  attended  by  much  ex¬ 
travasation  of  blood ;  and  after  death  the  brain-substance  is  found 
mixed  up  with  coagula,  and  forming  a  soft,  pulp3’',  bloody  mass.  In 
most  instances  that  I  have  seen,  the  anterior  lobes  have  been  thus  con¬ 
tused,  lacerated,  and  disorganized.  This  accident  may  occur  without 
any  fracture  of  the  skull  or  external  sign  of  serious  injurj",  and  usually 
results  from  falls  upon  the  back  or  side  of  the  head,  often  from  an 
inconsiderable  height,  as  when  a  person  slips  suddenly  up  in  frosty 
weather  and  strikes  his  head  on  the  pavement;  the  anterior  portions  of 
the  hemispheres  of  the  brain,  or  the  parts  opposite  to  that  struck,  will 
then  be  found  in  the  condition  just  described. 

The  brain  and  its  membranes  are  often  lacerated  by  the  sharp  spicida 
of  a  depressed  fracture  which  may  penetrate  to  a  considerable  depth  in 
its  substance.  And,  lastly,  the  injur}'-  may  be  occasioned  by  foreign 
bodies^  such  as  bullets,  traversing  or  lodging  in  the  head;  or  by  stabs 
and  punctures  through  the  thinner  portions  of  the  skull,  especially  the 
orbital  plate  of  the  frontal  bone.  In  this  wa}’-  a  piece  of  stick,  tobacco- 
pipe,  the  point  of  a  knife,  or  a  scissor-blade,  may  puncture  the  anterior 
part  of  the  brain. 

Symptoms  and  Effects. — The  symptoms  and  results  of  wound  or 
laceration  of  the  brain  vary  greatl}"  according  to  the  age  of  the  patient, 
the  seat  of  injuiy,  and  other  conditions  which  cannot  veiy  readil}-  be 
determined.  If  the  injury  implicate  those  portions  of  the  nervous 
centre  at  the  base  of  the  brain,  the  integrity  of  which  is  necessary  for 
the  proper  maintenance  of  the  respiratoiy  act,  immediate  death  must 
necessarily  ensue.  If,  however,  portions  of  this  organ  that  are  less 
essential  to  life,  as  the  anterior  lobes  and  upper  part  of  the  hemispheres, 
be  injured,  but  very  slight  s^’mptoms  ma}-  occur;  and  in  some  cases 
there  is  no  positive  indication  by  which  this  injuiy  of  the  cerebral  sub¬ 
stance  can  be  determined,  except  by  its  exposure  and  escape  through 
the  external  wound.  Hence,  even  the  worst  injuries  of  the  head  are 
rarely  immediately  fatal,  the  patient  being  seldom  killed  outright,  unless 
the  medulla  oblongata  or  pons  be  wounded.  Children,  especially,  have 
been  known  to  bear  extensive  injuries  of  the  brain,  and  even  the  loss  of 
a  considerable  quantity"  of  cerebral  matter,  without  any  very  serious 
effects,  either  immediate  or  remote ;  and  it  is  by  no  means  uncommon 
to  see  them  live  several  da^'S  with  an  extent  of  injury  to  the  brain 
which  would  rapidly  have  proved  fatal  to  an  adult.  Indeed  it  may  be 
stated  generall}',  that  the  younger  the  patient,  the  greater  the  chance  of 
recovery.  So,  also,  the  prognosis  may  be  considered  more  favorable  in 
men  of  the  laboring  class,  whose  minds  are  but  little  exercised,  than  in 
persons  of  more  cultivated  intellect.  Twitching  of  the  muscles  and 
epileptiform  fits  are  commonl}'-  met  with  when  the  brain  is  lacerated ; 
and,  these,  complicating  stertor,  or  alternating  with  it,  indicate  the 
nature  of  the  mischief. 

Foreign  bodies  even  of  large  size  and  considerable  weight  have  been 
lodged  for  a  considerable  time  within  the  skull,  in  contact  with  the  brain, 
without  occasioning  death.  Thus  Hennen  states  that  he  has  seen  five 
cases  in  which  bullets  were  lodged  within  the  skull,  that  did  not  prove 
immediately  fatal.  Cunningham  relates  the  case  of  a  boy  who  lived  for 
twent^^-four  days  with  the  breech  of  a  pistol,  weighing  nine  drachms, 


476 


INJURIES  OF  THE  HEAD. 


l3’ing  on  the  tentorium,  and  resting  against  the  occipital  bone.  O’Calla¬ 
ghan  has  recorded  the  remarkable  case  of  an  officer  who  lived  for  about 
seven  3’ears  with  the  breech  of  a  fowling-piece,  weighing  three  ounces, 
lodged  in  the  forehead  ;  the  right  hemisphere  of  the  brain  resting  on  the 
flat  part,  from  wffiich  it  was  onl3"  separated  b3^  false  membrane. 

From  the  great  variet3^  of  effects  produced  b3"  these  injuries,  it  must 
be  evident  that  there  can  be  no  one  set  of  S3’mptoms  indicative  of  wound 
of  the  brain,  provided  there  be  no  external  wound  through  which  the 
condition  of  the  cerebral  substance  can  be  ascertained.  In  those  cases 
in  which  this  does  not  exist,  we  can  at  most  onl3'  suspect  laceration,  if 
we  find  that  the  ordinaiy  S3'mptoms  of  compression  or  concussion  are 
associated  with  signs  that  do  not  usually  occur  in  those  conditions  when 
uncomplicated  ;  such  as  contraction  of  one  pupil,  dilatation  of  the  other, 
and  perhaps  an  alternation  of  these  states  wuth  twitchiugs  of  the  limbs, 
hemiplegia  of  one  side,  or  paral3’sis  of  an  arm  and  of  the  opposite  leg, 
with  perhaps  involuntaiy  spasmodic  movements  of  the  other  members. 
In  simple  uncomplicated  cerebral  compression,  the  pupils  are  always 
dilated.  In  laceration  of  the  brain  without  compression,  they  are  con¬ 
tracted.  When  laceration  and  compression  are  conjoined,  one  pupil  ma3’' 
be  dilated  and  the  other  contracted  ;  or  both  will  be  dilated  or  contracted, 
according  as  the  s3unptoms  of  compression  or  of  laceration  predominate. 
These  irregular  S3’mptoms,  when  accompanied  b3'  much  coldness  on  the 
surface,  slowness  of  pulse,  and  depression  of  vital  power,  may  generalU^ 
be  looked  upon  as  indicative  of  cerebral  laceration.  This  effect  of  the 
cerebral  lesion,  whether  it  assume  the  form  of  paral3’’sis  or  convulsions, 
is  alwa3’s  manifested  on  the  side  of  the  body  opposite  to  that  on  which 
the  injuiy  to  the  brain  exists;  but  not  necessarily  opposite  to  that  on 
which  the  blow  has  been  inflicted  on  the  head;  for  the  injuiy  to  the 
brain  ma3^,  ly'  counter-stroke,  be  in  that  cerebral  hemisphere  which  is 
opposite  to  the  side  of  the  head  that  has  been  struck.  Thus,  if  a  person 
struck  on  the  right  side  of  the  head  sustain  a  rupture  of  the  middle 
meningeal  arteiy,  and  have  extravasation  of  blood  on  the  right  hemi¬ 
sphere  of  the  brain,  he  will  have  hemiplegia  on  the  left  side,  and  mce 
verm.  But,  if  the  blow  that  is  inflicted  on  the  right  side  w’ere  to  give 
rise  to  extravasation  ly  counter-stroke  on  the  left  side  of  the  head,  the 
paral3^sis  w'ould  develop  itself  on  the  side  that  had  been  struck.  So  it  is 
with  convulsive  movements ;  the3^  will  occur  in  the  arms  and  legs,  on 
the  side  opposite  to  that  on  which  the  brain  has  been  injured,  whether 
that  injuiy  be  on  the  side  struck  from  direct  violence,  or  on  the  opposite 
side  from  counter-stroke.  In  this  wa3’'  the  hemiplegia  may  occur  on  one 
side,  and  the  convulsions  on  the  other.  A  man  was  struck  a  violent  blow 
on  the  right  temple.  He  was  seized  with  hemiplegia  and  facial  paral3’sis 
on  the  left  side,  and  with  convulsive  movements  on  the  right  side  of  the 
face,  the  right  arm,  and  leg.  He  died  a  few  days  after  the  injuiy.  On 
examination,  we  found  a  fissure  of  the  right  parietal  bone,  laceration  of 
the  middle  meningeal  arteiy,  and  a  large  clot  pressing  on  the  right  side 
of  the  brain.  Hence  the  hemiplegia  on  the  left  side  of  the  bod3^  There 
was  laceration  with  disorganization  of  the  middle  lobe  of  the  brain  on 
the  left  side.  Hence  the  convulsive  movements  of  the  right  side  of  the 
face,  bod3%  and  limbs. 

Saccharine  Diabetes  is  an  occasional  consequence  of  injuries  of  the 
brain.  A  man  43  years  of  age  was  admitted  into  Hospital  under  m3’'  care 
with  paral3’'sis,  the  result  of  a  fall  on  the  back  of  his  head.  On  examining 
his  urine,  it  was  found  to  contain  sugar  in  very  large  quantit3\  Previously 
to  the  accident,  he  had  been  perfectly  healtly  and  robust ;  and,  as  the 


WOUNDS  OF  THE  BRAIN. 


477 


paralytic  S3"mptoms  disappeared,  the  diabetic  sugar  gradually  lessened 
in  quantity,  until  it  ceased  entirely  to  be  formed,  and  this  notwithstand¬ 
ing  the  continued  use  of  saccharine  and  am^daceous  matter  in  the  food. 
Claude  Bernard  has  recorded  some  similar  instances  in  illustration  of 
the  interesting  physiological  fact  pointed  out  bj^  him,  that  wound  of  the 
central  portion  of  the  medulla  oblongata  and  irritation  of  the  fourth 
ventricle  of  the  brain  in  rabbits  occasion  saccharine  diabetes,  and  indeed, 
that  in  the  dog  artificial  traumatic  diabetes  may  be  induced  by  fracture 
of  the  skull  and  consecutive  injuiy  of  the  brain. 

The  Danger  of  wounds  of  the  brain  varies  greatly  according  to  the 
part  that  is  injured.  It  is  greatest  and  most  immediate  in  injuries  of 
the  base  of  the  brain,  of  the  pons,  and  crura  cerebri;  it  is  least  and 
most  remote  when  the  upper  and  anterior  part  of  the  hemispheres  is  the 
seat  of  lesion. 

The  Mode  of  Death  after  these  injuries  also  varies.  The}’’  may  prove 
fatal  either  at  once,  wdien  the  base  is  wounded,  by  the  injury  of  the 
respiratory  tract ;  in  the  course  of  a  few  hours,  by  the  continuance  of 
shock,  and  by  the  extravasation  of  blood  within  the  cranium ;  at  a  later 
period,  by  the  occurrence  of  encephalitis  and  its  consequences;  or  more 
remotely  still,  by  the  supervention  of  paralysis  and  other  ulterior  effects 
of  injury  of  the  nervous  system. 

The  Cerebral  Nerves  are  occasionally  injured  at  their  roots,  or  in  their 
deeper  parts  are  torn  across  or  detached  from  their  connection  wdth  the 
brain,  in  injuries  of  the  head.  These  nerves  may  be  w’ounded  by  the 
same  violence  that  injures  the  brain,  as  when  a  bullet  traverses  the  head; 
or  they  may  be  detached  from  their  connection  with  the  brain  in  lacera¬ 
tion  of  the  cerebral  pulp ;  or,  lastly,  they  may  be  torn  across  in  fracture 
of  the  base  of  the  skull  by  the  fissure  extending  across  the  foramen 
through  which  the  nerve  passes. 

Thus  blindness  may  result  from  injury  to  the  optic  nerve  at  any  part 
of  its  course;  ptosis,  and  strabismus  in  different  directions,  according 
as  the  third,  the  fourth,  or  the  sixth  nerve  has  been  injured.  But  the 
nerve  that  most  commonly  suffers  is  the  seventh,  which,  either  in  its 
facial  or  in  its  auditory  portion,  is  not  uncommonly  torn  across  in  frac¬ 
tures  of  the  petrous  portion  of  the  temporal  bone,  producing  either 
paralysis  of  the  face  or  deafness. 

Injury  to  the  eighth  nerve  is  not  common,  or  rather  it  is  not  common 
for  patients  long  to  survive  who  exhibit  evidence  of  the  lesion.  I  have, 
however,  seen  repeated  vomitings,  with  palpitations,  and  a  sense  of  suffo¬ 
cation  continuing  for  months  after  apparent  injury  to  the  origins  of  the 
pneumogastric.  In  other  cases,  from  lesion  to  the  spinal  accessory, 
spasm  of  the  trapezius  and  sterno-mastoid  muscles,  simulating  tetanus, 
may  set  in. 

Treatment. — In  the  treatment  of  injuries  of  the  brain,  little  can  be  done 
after  the  system  has  rallied  from  the  shock,  beyond  attention  to  strict 
antiphlogistic  treatment,  though  this  need  not  be  of  a  very  active  kind. 
In  these  cases,  indeed,  as  much  should  be  left  to  nature  as  possible,  the 
Surgeon  merely  removing  all  sources  of  irritation  and  excitement  from 
his  patient,  and  applying  simple  local  dressings. 

If  any  foreign  body  be  lodged  within  the  skull,  it  must  of  course  be 
removed,  if  possible.  This  maybe  done  if  it  be  situated  near  the  external 
wound,  or  fixed  in  the  bone ;  but  if  it  have  penetrated  deeply  into  the 
substance  of  the  brain,  and  have  gone  completely  out  of  reach,  it  would 
be  perhaps  more  dangerous  to  trephine  the  skull  on  the  chance  of  reach¬ 
ing  it,  or  in  any  other  way  to  go  in  search  of  it,  than  to  leave  it  where  it  is. 


478 


INJURIES  OF  THE  HEAD. 


Bullets  should  always  be  extracted  if  they  can  be  found.  On  this  point 
military  Surgeons  are  agreed.  If  they  enter  the  skull,  and  strike  against 
and  fracture  the  opposite  side  without  escaping,  should  they  be  sought 
for?  I  think  not.  Larrey  and  Bell,  it  is  true,  have  extracted  the  ball 
on  the  side  of  the  head  opposite  the  point  of  entrance.  But  it  may  not 
be  found  there.  In  a  case  of  suicide  to  which  I  was  called  some  years 
ago,  a  gentleman  had  shot  himself  through  the  right  temple ;  immediately 
opposite  the  wound,  on  the  left  temple,  was  a  raised,  loose  and  stellate 
fracture  of  the  skull,  over  which  the  scalp  was  uninjured.  I  cut  down 
on  this  and  removed  the  fragments  of  bone,  expecting  to  find  the  ball 
beneath  them  ;  but  in  this  I  was  disappointed,  and  after  death  the  bullet 
was  found  ljung  in  the  base  of  the  skull,  where  it  had  rolled. 

Fungus  or  Hernia  Cerebri. — In  those  cases  in  which  a  laceration  of 
the  brain  and  dura  mater  communicates  with  a  fracture  of  the  skull,  it  is 
occasionally  found,  more  particularly  in  children,  that  a  dark  brown  or 
bloody  fungous-looking  mass  of  cerebral  matter  protrudes  from  the 
wound.  The  period  after  the  receipt  of  an  injury  at  which  this  protrusion 
takes  place,  varies  from  a  few  days — eight  or  ten — to  several  weeks.  It 
has  been  remarked  bj^  Guthrie,  and  the  observation  has  been  fully  con¬ 
firmed,  that  hernia  cerebri  is  more  likely  to  take  place  through  small 
than  large  apertures  in  the  cranial  bones.  This  tumor  increases  rather 
rapidly,  pulsates  synchronously  w’ith  the  brain,  and  ma}’’  shortly  attain 
the  size  of  a  hen’s  egg,  or  even  become  larger.  In  its  composition  and 
structure  it  varies.  In  some  instances  it  is  composed  chiefiy,  if  not 
entirel}^,  of  extravasated  blood  ;  but  the  true  fungus  cerebri  is  composed 
of  softened  and  disintegrated  cerebral  matter,  infiltrated  with  lymph  and 
blood.  The  softening  of  the  brain,  with  red  discoloration,  extends  for 
some  little  distance  under  the  base  of  the  tumor.  The  mental  condition 
of  the  patient  is  in  many  cases  not  much  disturbed  at  first,  there  being 
merely  some  degree  of  cerebral  irritation.  Speedily,  however,  stupor 
comes  on,  and  death  eventually  occurs  from  encephalitis,  followed  by 
coma,  consequent  on  the  infiammatory  elfusions  that  take  place  within 
the  skull. 

Treatment. — The  treatment  of  this  complication  of  fractures  of  the 
skull  is  commonl}^  extremely  unsatisfactory.  If  the  tumor  be  shaved 
off,  as  usually  recommended,  it  generally  sprouts  again  until  the  patient 
is  destroyed  by  irritation  and  coma  conjoined.  In  some  fortunate  cases, 
however,  the  removal  of  the  tumor  is  not  followed  by  its  reproduction. 
All  that  can  be  done  is  to  slice  off  the  growth  on  a  level  with  the  brain ; 
to  apply  a  pledget  of  wet  lint,  and  a  compress  and  bandage  over  the  part, 
thus  allowing  it  to  granulate  and  the  wound  to  cicatrize. 

Extravasation  of  Blood  within  the  Skull  commonly  occurs  in 
all  injuries  of  the  head  accompanied  by  laceration  of  the  brain,  and  in 
many  of  those  in  which  the  skull  is  fractured  without  that  organ  being 
injured.  Indeed,  w'hen  we  refiect  on  the  great  vascularity  of  the  parts 
within  the  skull,  the  large  sinuses,  the  numerous  arteries  that  ramify 
both  within  the  bones  and  at  the  base  of  the  brain,  and  the  close  vas¬ 
cular  network  extended  over  the  surface  of  this  organ,  we  can  easilv 
understand  that  extravasation  of  blood  is  one  of  the  most  frequent  com¬ 
plications  of  these  injuries  and  a  common  cause  of  death,  when  they 
terminate  fatall}^  at  an  early  period  after  their  occurrence. 

Causes. — Intracranial  extravasation  of  blood  may  take  place  either 
with  or  without  fracture  of  the  skull.  "When  it  is  the  result  of  fracture, 
it  is  in  consequence  of  the  fissure  tearing  across  one  of  the  meningeal 
arteries  distributed  on  the  inside  of  the  skull,  or  of  a  fragment  of  bone 


EXTRAVASATION  OF  BLOOD  WITHIN  THE  SKULL.  479 


wounding  a  sinus  or  the  vascular  network  on  the  surface  of  the  brain ; 
or  it  may  proceed  from  laceration  of  this  organ  breaking  down  its  capil¬ 
lary  structure.  In  other  cases,  as  in  gunshot  wounds,  the  hemorrhage 
may  be  a  consequence  of  wound  of  the  vessels  by  the  bullet  or  other 
foreign  body  ;  but  it  may  also  be  the  result  of  apparentl}"  trivial  injuries 
of  the  head  without  bruise  or  wound  of  scalp,  or  fracture  of  skull  from 
the  rupture  by  concussion  of  one  of  the  meningeal  arteries. 

Situations _ The  extravasation  may  occur  in  four  situations:  1. 

Between  the  dura  mater  and  the  skull,  where  it  is  most  commonly  met 
with;  2.  Within  the  cavity  of  the  arachnoid;  3.  Upon  the  surface  of 
the  brain  ;  or,  4.  Within  its  substance  and  its  ventricles.  It  is  usually 
most  considerable  when  poured  out  upon  the  dura  mater,  or  within  the 
cavity  of  the  arachnoid  at  the  base  of  the  brain.  It  is  in  smallest  quan¬ 
tity  immediately  on  the  surface  of  that  organ,  or  within  its  substance. 
It  is,  however,  seldom  found  in  the  latter  situation  as  the  result  of  vio¬ 
lence,  without  being  met  with  more  superficiall3\  The  quantity  effused 
in  any  one  case  seldom  exceeds  four  ounces ;  and,  when  in  such  large 
quantity,  it  usually  proceeds  from  rupture  of  the  meningeal  artery. 

Results. — Extravasation  of  blood  is  one  of  the  most  frequent  causes 
of  death  in  injuries  of  the  head,  by  inducing  pressure  on  the  brain  and 
coma.  The  blood  that  is  extravasated  usually  coagulates  into  a  firm 
granular  clot.  There  can  be  no  doubt,  however,  that  extravasation  of 
blood  into  the  membranes  of  the  brain  frequently  occurs  without  being 
attended  by  fatal  consequences.  The  blood  that  is  so  extravasated  may 
undergo  various  changes :  1.  The  extravasated  blood  may  be  absorbed 
entirely ;  2.  The  serous  portions  and  coloring  matter  may  be  removed, 
leaving  a  fibrinous  buff-colored  clot,  which  may  eventually  become  organ¬ 
ized  ;  and  3.  The  exterior  of  the  clot  may  become  consolidated,  whilst 
the  interior  contains  fluid  and  disintegrated  blood. 

Symptoms. — The  symptoms  of  extravasation  are  often  by  no  means 
very  clear ;  being  those  of  compression,  associated  in  the  early  stages 
with  symptoms  indicative  of  laceration  of  the  brain,  and,  at  a  later 
period,  with  those  of  encephalitis.  Putting  out  of  consideration,  how¬ 
ever,  these  complications,  the  more  special  symptoms  of  compression  from 
extravasated  blood  may  occur  in  two  ways. 

Ill  the  first  variety  there  are  three  distinct  stages,  viz.,  concussion,  a 
return  and  some  continuance  of  consciousness,  and  then  coma  gradually 
supervening.  The  patient  is  concussed  or  stunned  as  usual,  after  the 
receipt  of  a  blow  on  the  head ;  from  this  he  quickly  rallies,  and  then 
symptoms  of  compression  set  in,  and  gradually  increase  in  intensity. 
He  becomes  drowsy  and  dull,  with  a  slow  and  laboring  pulse,  dilated 
and  sluggish  pupils,  and  a  tendency  to  slow  respiration;  as  the  com¬ 
pression  increases,  complete  stupor  at  length  comes  on,  with  stertor  in 
breathing,  and  there  is  either  general  paral^^sis,  or  hemiplegia  of  the  side 
opposite  to  the  seat  of  injury. 

When  the  symptoms  run  this  regular  course,  it  is  probable  that  the 
extravasation  results  from  injury  of  one  of  the  meningeal  arteries  or 
large  venous  sinuses;  that  the  extravasation  is  confined  to  the  mem¬ 
branes  of  the  brain ;  and  that  there  is  no  laceration  of  the  substance  of 
this  organ.  This  may  be  termed  the  Meningeal  Extravasation ;  it 
most  commonly  arises  from  rupture  of  the  middle  meningeal  artery, 
which,  from  its  situation  in  a  deep  canal  in  the  parietal  bone,  is  pecu¬ 
liarly  apt  to  be  torn  in  injuries  of  the  side  of  the  skull. 

More  commonly,  however,  the  patient  never  recovers  his  consciousness 


480 


INJURIES  OF  THE  HEAD. 


after  having  been  stunned,  the  s3"mptoms  of  concussion  speeclil}’'  pass¬ 
ing  into  those  of  compression.  In  these  cases  the  paralj^sis  is  commonl}^ 
incomplete,  and  is  associated  with  twitchings  of  the  limbs  or  convulsive 
movements  of  the  bod}’’  generall}",  and  much  restlessness  with  incohe¬ 
rent  muttering:  the  pupils  are  sometimes  contracted,  sometimes  dilated, 
and  occasional!}"  squinting  is  observed.  It  is  especially  when  there  are 
convulsions,  that  the  pupils  are  observed  to  be  in  different  conditions  ; 
and  I  have  most  frequently  noticed  the  pupil  dilated  on  the  side  that  is 
most  convulsed.  The  extravasation  is  probably  connected  with  and 
dependent  on  laceration  or  disorganization  of  a  portion  of  the  brain, 
and  may  consequently  be  termed  the  Cei'ehral  Extravasation, 

Diagnosis. — The  diagnosis  of  these  two  forms  of  extravasation  from 
one  another  is  important,  as  it  is  in  the  meningeal  only  that  any  opera¬ 
tive  procedure  can  be  successfully  undertaken:  and  it  may  usually 
readily  be  effected  by  attention  to  the  symptoms  just  detailed. 

The  diagnosis  between  the  compression  from  extravasation  and  that 
from  depressed  hone  or  in  flammatory  effusions  within  the  skull,  is  easily 
made.  In  the  case  of  depressed  fracture,  the  symptoms  of  compression 
continue  uninterruptedly  from  the  very  first,  and  proper  examination  of 
the  skull  will  always  lead  to  the  detection  of  the  injured  bone.  When 
inflammatory  eflTusions,  whether  of  pus,  lymph,  or  serum,  exercise  undue 
pressure  upon  the  brain,  the  signs  of  compression  are  preceded  by 
symptoms  of  cerebral  inflammation,  and  are  accompanied  by  a  good 
deal  of  pyrexia,  by  quick  pulse  and  hot  skin ;  the  character  af  the  scalp- 
w'ound  likewise,  and  the  separation  of  the  dura  mater  when  pus  is 
effused,  enable  us  to  distinguish  this  condition  from  that  in  which  the 
pressure  is  the  result  of  extra vasated  blood. 

From  apoplexy,  the  diagnosis  is  not  always  easily  made,  more  particu¬ 
larly  when  there  is  no  evidence  that  the  head  has  been  injured.  A  man 
was  brought  to  University  College  Hospital  in  a  state  of  profound 
coma,  in  which  condition  he  had  been  found  lying  in  the  street.  There 
was  no  evidence  of  injury  about  the  head,  beyond  a  bruise,  which  had 
probably  been  received  when  he  fell.  The  case,  which  was  snpposed  to 
be  one  of  apoplexy,  and  treated  accordingly,  proved  fatal  in  a  few  hours. 
On  examination  after  death  the  skull  was  found  fractured,  but  not  de¬ 
pressed.  On  the  opposite  side  to  the  bruise  and  fracture,  a  coagulum, 
weighing  nearly  four  ounces  and  compressing  the  brain,  lay  between  the 
dura  mater  and  bone.  In  such  a  case,  it  is  evident  that  the  history  can 
alone  afi’ord  a  clue  to  its  true  nature.  Even  when  the  head  has  been 
injured,  it  is  not  always  easy.  A  man  was  admitted  under  my  care, 
comatose.  A  fortnight  previously,  he  had  been  struck  on  the  left  side 
of  the  head  behind  the  ear.  He  was  stunned,  bled  freely  from  the  left 
ear,  but  then  recovered  tolerably,  and  went  about  his  avocations  as 
usual  until  the  day  before  his  admission,  when  he  became  suddenly 
comatose.  There  were  stertor,  quick  pulse,  and  some  heat  of  head  ;  the 
right  pupil  was  natural,  the  left  contracted.  He  was  treated  antiphlo- 
gistically,  but  died  on  the  third  day.  On  examination,  a  fracture  on  the 
left  side  of  the  skull  was  found,  extending  into  the  left  internal  meatus ; 
on  the  right  side  of  the  head,  immediately  opposite  the  fracture  and  the 
seat  of  injury,  there  was  a  large  coagulum  in  the  cavity  of  the  arachnoid, 
with  some  sero-plastic  exudation  about  it.  Here  was  a  meningeal 
extravasation,  the  result  of  contrecoup,  existing  without  symptoms  for 
fourteen  days,  and  then  proving  rather  suddenly  fatal  by  inflammation. 

The  insensibility  of  drunkenness  may  usually  be  distinguished  from 
the  coma  resulting  from  injuries  of  the  head,  by  the  absence  of  local 


TREATMENT  IN  EXTRAVASATION. 


481 


mischief,  by  the  smell  of  the  breath,  and  by  the  face  of  the  drunkard 
being  flushed  and  turgid,  and  not  pale  as  in  a  person  who  is  suffering 
from  the  effects  of  a  severe  injury.  When  a  drunken  person  has  met 
with  an  injury  of  the  head  and  is  insensible,  he  should  always  be  care¬ 
fully  watched,  however  slight  the  injury  ma}^  appear  to  be,  until  sufiicient 
time  has  elapsed  for  him  to  recover  from  his  drunken  flt ;  as  it  is  impos¬ 
sible  to  say  whether  the  stupor  be  the  result  of  intoxication,  or  of 
mischief  within  the  skull;  and  I  have  known  cases  to  be  sent  away  from 
hospitals  as  drunk,  when  in  reality  the  stupor  was  occasioned  by  de¬ 
pressed  bone. 

In  the  stupor  from  poisoning  by  opium^  the  condition  of  the  pupils, 
which  are  contracted  to  the  size  of  a  pin’s  point,  instead  of  being  widely 
dilated  as  in  coma  from  cerebral  compression,  will  enable  the  Surgeon 
to  make  the  diagnosis. 

The  Treatment  of  extravasation  of  blood  may  be  conducted  on  two 
principles;  either  b}"  means  of  general  and  local  antiphlogistic  measures, 
having  for  their  object  the  arrest  of  farther  hemorrhage,  the  promotion 
of  absorption,  and  the  subdual  of  inflammatory  action ;  or  else  by  the 
application  of  the  trephine,  with  a  view  of  allowing  the  escape  of  the 
effused  blood. 

The  line  of  treatment  to  be  adopted  should,  I  think,  have  reference 
to  the  character  of  the  symptoms.  When  these  indicate  cerebral  ex¬ 
travasation,  trephining  can  be  of  little  service,  and  we  must  be  content 
with  general  anti-inflammatory  measures;  but  wdien  the  extravasation 
seems  to  be  meningeal^  then  an  attempt  may  be  successfully  made  to 
evacuate  the  extravasated  blood. 

Although  Trephining  in  cases  of  extravasation  was  formerly  much 
in  vogue,  it  is  seldom  had  recourse  to  by  modern  Surgeons,  and  it  is 
only  proper  in  the  meningeal  form  of  extravasation.  It  is  very  true 
that,  if  it  can  be  ascertained  without  doubt  that  the  extravasation  is 
not  onl3’^  meningeal,  but  that  it  is  so  situated  that  the  blood  may  be 
removed  through  the  trephine-aperture,  and  if  there  be  no  other  serious 
injury  to  the  brain  or  skull,  the  operation  should  at  once  be  performed. 
And  doubtless  the  case  occasional!}^  happens  in  which,  from  the  situa¬ 
tion  of  the  blow,  and  perhaps  the  presence  of  a  capillary  Assure  over 
the  course  of  the  middle  meningeal  arteiy,  the  gradual  supervention 
of  signs  of  compression  after  an  interval  of  consciousness,  and  the 
occurrence  of  hemiplegia  on  the  side  opposite  to  that  which  has  been 
struck,  the  Surgeon  is  warranted  in  making  an  aperture  in  the  skull 
at  the  seat  of  injuiy,  in  order  to  remove  the  blood  that  has  been 
poured  out,  and  to  arrest  its  further  effusion.  But  the  instances  in 
wdiich  this  assemblage  of  symptoms  could  exist,  with  sufficient  precision 
to  justify  an  operation,  are  excessivefy  rare.  Out  of  some  hundred 
cases  of  serious  and  fatal  injury  of  the  head  that  have  been  admitted 
into  Universify  College  Hospital  during  the  last  twenfy-four  5"ears,  in 
three  cases  onfy^,  I  believe,  has  it  been  found  advisable  to  have  recourse 
to  trephining  for  the  removal  of  extravasated  blood.  In  two  of  these 
cases  death  speedify^  ensued,  the  coma  being  unrelieved  b}' the  operation. 
In  the  third  case,  recoveiy  took  place.  The  successful  case  to  which  I 
refer  was  that  of  a  man  admitted  comatose,  three  days  after  receiving 
an  injur}^  of  the  head  b}'  a  fall  from  a  cab.  There  were  no  serious 
s^^mptoms  for  some  hours  after  the  accident;  but  then  stupor  gradualfy 
came  on,  amounting  at  last  to  complete  coma.  On  examination,  a 
bruise  of  the  scalp  was  found  on  the  left  temple  :  through  this  I  made 
an  incision,  and  finding  a  starred  fracture  over  the  sinus  of  the  middle 
VOL.  I. — 31 


482 


INJURIES  OF  THE  HEAD. 


meningeal  arteiy,  trephined  the  bone,  when  a  large  coagnlum  was  found 
lying  upon  the  dura  mater,  and,  on  removing  this,  fluid  arterial  blood 
freely  welled  up.  The  coma  -was  relieved,  and  the  patient  made  a  good 
recoveiy.  It  must  be  borne  in  mind  that,  however  clear  the  signs, 
extravasation  may  not  be  met  with  where  the  Surgeon  expects  to  find 
it.  In  these  circumstances,  it  is  better  not  to  prosecute  the  search  by 
making  fresh  trephine-apertures.  In  no  case  would  a  prudent  Surgeon 
trephine  over  the  course  of  the  middle  meningeal  arteiy  in  the  absence 
of  local  symptoms,  on  the  chance  of  finding  the  blood  there,  as  has  been 
recommended  by  some  of  the  older  Surgeons.  The  most  serious  objec¬ 
tion  to  the  application  of  the  trephine  in  cases  of  extravasation  does 
not,  however,  consist  so  much  in  the  difficulty  of  determining  that 
blood  has  been  effused  within  the  skull,  or  that  the  extravasation  is  of 
the  meningeal  form,  as  in  the  difficulty  of  diagnosing  that  it  is  so  seated 
between  the  dura  mater  and  the  skull  as  to  admit  of  removal;  not  being 
eflfused  at  the  base,  nor  so  widely  coagulated  over  the  surface  of  the 
brain  as  to  be  unable  to  escape  through  the  aperture  that  may  be  made. 
The  likelihood  of  the  coexistence  of  fracture  of  the  base  of  the  skull 
and  of  laceration  of  the  brain,  giving  rise  to  the  cerebral  form  of  ex¬ 
travasation,  must  also  be  taken  into  account.  For  these  various  reasons. 
Surgeons  now  very  properl}"  content  themselves,  in  the  great  majority 
of  cases  of  extravasation,  with  the  employment  of  anti-innammatory 
treatment,  on  the  principles  already  stated.  The  head  should  be  shaved, 
the  ice-bladder  applied,  the  patient  bled,  purged,  and  kept  at  perfect 
rest.  If,  however,  the  signs  be  urgent,  and  pretty  clearly  indicate  the 
meningeal  form  of  extravasation,  and  more  especially  if  there  be  hemi¬ 
plegia  on  the  side  opposed  to  that  on  which  the  blow  has  been  received, 
with  an  injury  in  the  course  of  the  middle  meningeal  arteiy,  the  trephine 
may  be  applied  at  the  seat  of  injury  and  the  blood  removed. 

Operation  of  Trephining. — Before  concluding  the  subject  of  inju¬ 
ries  of  the  head,  it  is  necessary  to  sa}"  a  few  words  on  the  operation  of 
Trephining,  which,  though  far  less  commonly  emplo3"ed  in  the  present 
day  than  heretofore,  is  one  of  sufficient  frequency  in  practice,  as  well 
as  of  great  importance  from  the  serious  nature  of  the  cases  that  usually 
require  it. 

The  trephine  may  be  applied  to  the  skull  for  two  purposes ;  either 
with  the  view  of  preventing  inflammation  and  its  consequences,  or  for 
the  purpose  of  removing  some  cause  of  compression.  The  only  case  in 
which  preventive  trephining  is  practised  by  modern  Surgeons,  is  that  of 
the  punctured  or  starred  fracture  of  the  skull,  without  stupor ;  in  all 
other  instances  in  which  it  is  called  for,  the  object  of  its  application  is 
the  removal  of  a  cause  of  compression  or  of  irritation  of  the  brain, 
such  as  a  depressed  portion  of  bone,  foreign  bodies  either  fixed  in  the 
skull  or  lying  close  under  it,  or  pus  or  blood  extravasated  within  the 
cranial  cavity. 

The  trephine  should  have  a  well-tempered  crown,  serrated  half-way 
up  its  exterior ;  the  teeth  should  be  short  and  broad,  and  not  too  fine  ; 
the  centre-pin  must  not  project  more  than  about  the  eighth  of  an  inch, 
and  care  must  be  taken  that  the  screw  which  fixes  it  is  in  good  working 
order.  The  other  instruments  required  are  a  Key’s  saw,  an  elevator  that 
will  not  readil}''  snap,  and  a  pair  of  strong  dissecting-forceps. 

The  operation  itself  should  be  conducted  in  the  following  way :  The 
head  having  been  shaved,  and  the  portion  of  the  skull  to  which  the 
trephine  is  to  be  applied  having  been  freely  exposed  b}"  means  of  a 
crucial  or  T-shaped  incision,  or  by  the  enlargement  of  any  wound  that 


OPERATION  OF  TREPHINING. 


483 


ma}"  exist,  the  trephine,  with  the  centre-pin  protruded  and  well  screwed 
down,  is  to  be  firmly  applied  until  its  teeth  touch  the  skull;  it  is  then 
worked  with  rather  a  sharp,  light,  and  quick  movement,  the  pressure 
being  exercised  as  the  hand  is  carried  from  left  to  right.  The  centre-pin 
must  be  withdrawn  so  soon  as  a  good  groove  is  formed  by  the  crown, 
lest  it  perforate  the  skull  first  and  injure  the  dura  mater.  In  this  wa}" 
the  outer  table  of  the  skull  is  quickh'  divided,  and  the  diploe  cut  into ; 
the  detritus  which  now  rises  by  the  crown  of  the  trephine  is  soft  and 
blood}*,  instead  of  being  dry,  as  it  is  whilst  the  outer  table  is  being 
sawn.  As  the  instrument  approaches  the  dura  mater,  the  sawing  must  be 
conducted  more  warily,  and  must  every  now  and  then  be  interrupted,  in 
order  that  the  Surgeon  may  examine  with  the  fiat  end  of  a  probe,  or 
with  a  quill,  the  depth  that  has  been  obtained,  care  being  taken  that  this 
is  uniform  throughout  the  circle.  The  Surgeon  now  makes  each  turn 
very  lightly,  and  now  and  then  tries  with  a  slight  to-and-fro  movement 
whether  the  circle  of  bone  is  loose.  So  soon  as  it  is,  he  withdraws 
it  in  the  crown  of  the  trephine,  or  raises  it  out  by  means  of  the  elevator. 
In  this  operation  the  dura  mater  must  not  be  wounded ;  if  it  be  injured, 
fatal  consequences  will  probably  ensue.  The  objects  for  which  the 
trephining  has  been  had  recourse  to  must  now  be  carried  out,  depressed 
bone  being  elevated  or  removed,  and  pus  or  blood  evacuated.  The  scalp 
should  then  be  laid  down  again,  a  few  sutures  and  a  piece  of  water¬ 
dressing  being  applied. 

There  are  certain  parts  of  the  skull — over  the  venous  sinuses,  for 
instance,  and  near  the  base — to  which  no  prudent  Surgeon  would  apply 
the  instrument.  So,  also,  if  it  were  ever  thouglit  necessaiy  to  trephine 
at  the  frontal  sinuses,  the  outer  table  must  first  be  removed  with  a  large 
crown,  and  the  inner  table  sawn  out  with  a  smaller  one. 

After  the  operation,  careful  attention  must  be  paid  to  antiphlogistic 
measures  of  a  preventive  and  curative  kind,  the  great  direct  danger  to 
be  apprehended  being  inflammation  of  the  brain  and  its  membranes.  In 
some  cases,  also,  there  is  reason  to  believe  that  suppurative  phlebitis  of 
the  sinuses  and  veins  of  the  diploe  has  been  the  cause  of  death. 

The  operation  of  trephining  is  by  no  means  a  favorable  one  in  its 
results.  Of  45  cases  reported  by  Lente,  as  occurring  at  the  Xew  York 
Hospital  (in  which,  however,  there  is  no  distinction  made  between  the 
application  of  the  trephine  proper  and  of  various  instruments,  such  as 
the  elevator,  Ha3*’s  saw,  etc.,  belonging  to  a  trephining  case),  only  II, 
or  about  one-fourth,  recovered.  Of  IT  cases  in  which  the  trephine  proper 
was  used  at  University  College  Hospital,  by  Cooper,  Liston,  and  m3*self, 
6  patients  recovered;  I  other  died  of  injury  of  the  spine  unconnected 
with  the  operation,  and  the  remaining  10  died  from  various  causes.  In 
the  late  American  war,  the  results  have  been  more  satisfactory  than  the 
previous  experience  of  Army  Surgeons  would  have  led  us  to  hope.  Of 
lOT  cases  of  trephining,  4T  recovered;  and  of  114  cases  where  frag¬ 
ments  of  bone  were  removed  by  the  forceps  and  elevator,  without  the 
use  of  the  trephine,  53  recovered.  The  Parisian  Surgeons  have  not 
been  veiy  successful.  Xelaton  says  that  all  the  cases  of  injury  of  the 
head,  16  in  number,  in  which  the  trephine  had  been  used  in  the  Parisian 
Hospitals  during  fifteen  3*ears,  terminated  fatally. 

But,  although  cases  in  which  the  trephine  is  used  thus  commonly 
terminate  fatally,  it  would  not  be  right  to  attribute  the  unfavorable 
result  to  the  operation  itself.  In  the  majority  of  cases,  death  results 
rather  from  the  injuiy  sustained  b}*  the  brain,  from  the  pressure  of 
extravasated  blood  at  the  base,  or  from  encephalitis  induced  b}*  the 


484 


INJURIES  OF  THE  SPINE. 


cerebral  lesion.  And,  as  the  cases  to  which  modern  Surgeons  now 
restrict  the  use  of  the  trephine  would  necessarily  prove  fatal  if  left  to 
themselves,  it  is  but  right  to  give  the  patient  the  slender  chance  of  one 
to  four  of  escaping  with  life. 


CHAPTER  XXV. 

INJURIES  OF  THE  SPINE. 

Injuries  of  the  spine,  like  those  of  the  head,  derive  their  importance 
from  the  degree  to  which  the  inclosed  nervous  centre  is  implicated. 

The  spinal  cord  is  subject  to  Concussion^  Compression^  and  Injiamma- 
tion,  as  the  result  of  external  violence ;  and  aii}^  of  those  conditions  may 
occur  without  injury  to  the  osseous  and  ligamentous  structures  investing 
it,  although,  in  the  majority  of  cases,  they  are  directly  occasioned  by  frac¬ 
ture  or  dislocation  of  the  vertebrae.  It  may  also  be  partially  or  completely 
divided  by  cutting  instruments,  gunshot  wounds,  or  broken  vertebrae. 

CONCUSSION  OF  THE  SPINAL  CORD. 

It  is  by  no  means  easy  to  give  a  clear  and  comprehensive  definition  of 
the  term.  Concussion  of  the  Spinal  Cord.  This  phrase  is  generally 
adopted  by  Surgeons  to  indicate  a  certain  state  of  the  cord  occasioned 
by  external  violence ;  a  state  that  is  independent  of,  and  usually  but 
not  necessarily  uncomplicated  with,  any  obvious  lesion  of  the  vertebral 
column,  such  as  fracture  or  dislocation ;  a  condition  that  is  supposed  to 
depend  upon  a  shake  or  jar  received  by  the  cord,  by  which  its  intimate 
organic  structure  may  be  more  or  less  deranged,  and  by  which  its  func¬ 
tions  are  certainly  greatly  disturbed,  various  symptoms  indicative  of  loss 
or  modification  of  innervation  being  immediately  or  remotely  induced. 

It  appears  that  Surgeons  and  writers  on  diseases  of  the  nervous  system 
have  included  four  distinct  pathological  conditions  under  this  one  term, 
concussion  of  the  spinal  cord  ;  viz.,  I.  A  jar  or  shake  of  the  cord,  dis¬ 
ordering,  to  a  greater  or  less  degree,  its  functions,  without  any  lesion 
cognizable  to  the  unaided  eye ;  2.  Compression  of  the  cord  from  extra- 
vasated  blood ;  3.  Compression  of  the  cord  from  infiammatory  exudations 
within  the  spinal  canal,  whether  of  serum,  lymph,  or  pus ;  and,  4.  Chronic 
alterations  of  the  structure  of  the  cord,  as  the  result  of  impairment  of 
nutrition  consequent  on  the  occurrence  of  one  or  other  of  the  preceding 
pathological  states,  but  chiefly  of  the  third.  These  various  conditions 
differ  remarkably  from  one  another  in  symptoms  and  effects,  and  have 
only  this  in  common,  that  they  are  not  dependent  upon  an  obvious 
external  injury  of  the  spine  itself;  in  which  respect  they  differ  from  the 
laceration  or  compression  of  the  cord  by  the  fracture  with  displacement 
or  the  dislocation  of  a  vertebra. 

Symptoms  indicative  of  concussion  of  the  spinal  cord  have  of  late 
years  frequentl}^  occurred,  in  consequence  of  injuries  sustained  in  railway 
collisions,  and  have  been  forcibly  brought  under  the  observation  of 
Surgeons  in  consequence  of  their  having  been  the  fertile  sources  of 
litigation;  actions  for  damages  for  injuries  alleged  to  have  been  sustained 
in  railway  collisions  having  become  of  such  verj'  frequent  occurrence  as  now 


CONCUSSION  FROM  DIRECT  VIOLENCE. 


485 


to  constitute  a  very  important  part  of  medico-legal  inquiry.  The  symp¬ 
toms  arising  from  these  accidents  have  been  very  variously  interpreted. 
Some  practitioners  have  ignored  them  entirely,  believing  that  they  exist 
only  in  the  imagination  of  the  patient ;  or,  if  admitting  their  existence, 
have  attributed  them  to  other  conditions  of  the  nervous  system  than  any 
that  could  arise  from  the  alleged  accident.  And  when  their  connection 
with,  and  dependence  upon,  an  injury  have  been  incontestably  proved,  no 
little  dicrepancy  of  opinion  has  arisen  as  to  the  ultimate  result  of  the 
case,  the  permanence  of  the  symptoms,  and  the  curability  of  the  patient. 
I  cannot  too  strongly  urge  the  fact  that  there  is  in  reality  nothing  special 
in  the  symptoms  of  concussion  of  the  spine  produced  by  railway  collisions, 
except  in  the  severity  of  the  accident  by  which  the  concussion  was  occa¬ 
sioned,  and  that  it  is  consequently  an  error  to  look  on  a  certain  class  of 
symptoms  as  special  to  railway  accidents.  Injuries  received  on  railways 
may  differ  in  their  severity,  but  do  not  do  so  in  their  nature,  from  injuries 
received  in  the  other  accidents  of  civil  life.  There  is  no  more  real  differ¬ 
ence  between  that  concussion  of  the  spine  which  results  from  a  railway 
collision  and  that  which  is  the  consequence  of  a  fall  from  a  horse  or  a 
scaffold,  than  there  is  between  a  compound  and  comminuted  fracture  of 
the  leg  occasioned  by  the  grinding  of  a  railway  carriage  over  the  limb 
and  that  resulting  from  the  passage  of  the  wheel  of  a  street  cab  across 
it.  In  either  case,  the  injury  arising  from  the  railway  accident  will  be 

essentiallv  of  the  same  nature  as  that  which  is  otherwise  occasioned : 

*/  / 

but  it  will  probably  be  infinitely  more  severe  and  destructive  in  its 
effects,  owing  to  the  greater  violence  that  occasions  it. 

Concussion  of  the  spinal  cord  may  be  produced  either  by  direct  violence^ 
as  by  severe  blows  or  falls  on  the  back,  giving  rise  to  local  pain  and  signs 
of  contusion,  or  by  slight  blows  ;  or  by  indirect  violence^  as  when  a  person 
meets  with  a  general  fall,  jar,  or  concussion  of  the  bod}",  without  any 
evidence  of  a  blow  having  been  inflicted  on  the  spine  itself. 

Concussion  from  Direct  Violence.— Concussion  or  commotion 
of  the  spinal  cord,  as  a  consequence  of  severe  and  direct  blows  upon  the 
back,  has  long  been  recognized  and  described  by  those  writers  who  have 
occupied  themselves  with  the  consequences  of  accidents  to  this  part  of 
the  body. 

The  Primary  Symptoms  of  concussion  of  the  cord  immediately  and 
directly  produced  by  a  severe  blow  upon  the  spine  will  necessarily  vary 
in  severity  and  extent  according  to  the  situation  of  the  injury,  the  force 
with  which  it  has  been  inflicted,  and  the  amount  of  organic  lesion  that 
the  delicate  structure  of  the  cord  has  sustained  from  the  shock  or  jar  to 
which  it  has  been  subjected.  A  severe  blow  upon  the  Upper  Cervical 
Region  may  produce  instantaneous  death.  A  less  severe  blow  on  this 
region  may  give  rise  to  various  phenomena,  dependent  on  irritation  of 
the  large  nerves  that  take  their  origin  from  the  medulla  oblongata. 
Thus,  when  the  vagus  nerve  is  affected,  a  sense  of  suffocation,  with 
irregular  action  of  the  heart,  may  be  experienced,  or  severe  vomiting 
may  be  established,  and  may  continue  for  months.  Sometimes  the  spinal 
accessory  is  affected,  and  the  trapezius  or  the  sterno-mastoid  muscle 
thrown  into  a  more  or  less  permanent  spasmodic  state.  From  irritation 
of  the  phrenic  nerve  hiccup  and  a  peculiar  sense  of  constriction  round 
the  bod}^,  as  if  the  patient  were  girt  by  an  iron  band,  may  be  established. 

When  the  Lower  Part  of  the  Cervical  Spine  has  been  struck  so  as  to 
concuss  the  cord,  I  have  known  paral3"sis  of  one  or  both  arms  induced, 
without  any  parah"tic  symptoms  of  the  trunk  or  legs.  In  these  cases 
paralysis  may  go  off  entirely;  or  it  may  disappear  in  one  arm  and  con- 


486 


INJURIES  OF  THE  SPINE. 


tinue  in  another ;  or  one  nerve  only  may  continue  to  be  affected — such 
as  the  circumflex^  the  musculo-spiral^  or  the  ulnar.  There  may  be 
complete  paralysis  of  sensation  and  of  motion  in  a.i\y  one  of  these 
nerves ;  or  motor  power  may  be  lost,  whilst  sensation  is  normal ;  or, 
more  commonly,  where  the  sensibility  continues,  it  is  exalted,  and  we 
may  find  loss  of  motor  power  with  hyperesthesia.  These  modifications 
of  innervation  may  be  confined  to  one  nerve,  as  the  musculo-spiral,  when 
there  may  be  loss  of  motor  power  in  the  extensors  and  supinators  of  the 
forearm  and  hand,  with  loss  of  sensation  or  hyperesthesia  of  the  skin  of 
the  hand  supplied  by  the  radial  nerve.  In  other  cases  we  find  motor 
paral3^sis  of  the  circumflex  or  musculo-spiral  nerves,  or  h^'perethesia  of 
the  ulnar.  In  these  respects  there  is  every  possible  variety. 

A  severe  blow  inflicted  on  the  Dorsal  or  the  Lumbar  Region  may 
induce  more  or  less  complete  paraplegia.  In  some  cases  the  paral^^sis  of 
the  lower  limbs  has  been  complete  and  instantaneous  ;  and  has  afiected 
both  sensation  and  motion,  with  loss  of  power  over  the  sphincters.  In 
other  cases  there  has  only  been  paralj'sis  of  motion,  sensation  continuing 
perfect  or  being  in  excess.  The  reverse  has  been  met  with,  but  less  fre- 
quentl}’’  and  less  completel3q  there  being  loss  of  sensation,  and  impair¬ 
ment,  though  not  complete  loss,  of  power  over  motion.  One  leg  is 
frequently  more  severely'  affected  than  the  other.  Or  the  two  legs  may 
be  unequall}’-  affected  as  to  sensation  and  motion ;  both  sensation  and 
motion  being  impaired,  but  in  vaiying  degrees  in  the  two  limbs.  There 
may  be  complete  loss  of  power  over  the  sphincters  both  of  the  bladder 
and  anus,  with  incontinence  or  retention  of  urine  and  feces  ;  or  the  loss 
of  power  may  be  confined  to  the  bladder  onl3^  This  is  especially’-  the 
case  when  there  is  paraly’sis  of  motion  rather  than  of  sensation  in  the 
lower  limbs.  The  state  of  the  urine  will  vaiy.  If  there  be  no  retention, 
it  will  continue  acid.  When  there  is  retention,  the  urine  usually  becomes 
alkaline,  but  sometimes,  even  when  there  is  complete  retention,  it  remains 
strongly"  acid;  and  Ollivier  noted  the  very  remarkable  circumstance  in 
one  case  of  retention,  that  tliere  was  an  enormous  formation  of  uric  acid, 
so  that  the  catheter  became  loaded  with  it.  Priapism  does  not  occur  in 
concussion,  while  it  does  so  often  in  cases  of  laceration  and  irritation  of 
the  cord. 

The  Temperature  of  the  paralyzed  parts  is  generally’-  notably"  lower 
than  that  of  the  healthy"  parts  of  the  body",  and  in  some  cases  an  absence 
of  normal  perspiration  has  been  observed. 

The  Secondary  Symptoms  of  severe  concussion  of  the  spine  are  usually 
those  of  the  development  of  inflammation  in  the  meninges  and  in  the 
cord  itself.  They"  consist  in  paw  in  some  part  or  parts  of  the  spine, 
greatly-  increased  by"  pressure  and  on  motion,  and  consequent  rigidity 
of  the  vertebral  column,  the  patient  moving  it  as  a  whole.  The  pain  is 
greatly  increased  by"  all  movements,  but  especially"  by"  those  of  rotation. 
It  frequently"  extends  down  the  limbs  or  around  the  body",  giving  the 
sensation  of  a  cord  tied  tightly". 

If  the  case  go  on  to  the  development  of  acute  inflammatory"  action  in 
the  cord  and  its  membranes,  spasms  of  a  serious  character  come  on ;  at 
first,  usually"  of  the  nature  of  trismus  ;  then  general  spasms  of  the  body 
and  limbs,  mostly  followed  by  speedy"  death  from  the  exhaustion  pro¬ 
duced  by"  their  repetition. 

If  the  inflammation  become  chronic  and  subacute,  j^ermanent  altera¬ 
tions  in  the  structure  of  the  cord  will  ensue,  leading  to  incurable  para¬ 
lytic  affections,  usually"  confined  to  the  lower  extremities,  but  sometimes 


CONCUSSION  FROM  DIRECT  VIOLENCE. 


487 


influencmg  the  brain,  and  associated  with  great  and  deep-seated  derange¬ 
ment  of  the  general  health. 

White  softening  of  the  cord^  unassociated  with  signs  of  inflammation 
of  it  or  its  membranes,  may  be  the  result  of  a  blow  on  the  back.  In 
this  condition  paralysis  of  sensation  or  motion,  often  accompanied  by 
peculiar  rigidity  of  the  muscles,  may  come  on,  and  ultimately  advance 
to  general  paralysis. 

Causes  of  Death, — Concussion  of  the  spinal  cord  from  a  severe  and 
direct  blow  upon  the  back  may  prove  fatal  at  very  different  periods,  de¬ 
pending  partly  on  the  situation  of  the  blow,  and  in  a  great  measure  on 
the  lesions  to  which  it  has  given  rise.  Sadden  and  fatal  paralysis  has 
'  often  been  incurred,  without  leaving  after  death  any  lesion  of  the  cord 
that  could  be  assigned  as  the  cause  of  death.  Abercrombie  says, 
‘‘  Concussion  of  the  cord  may  be  speedily  fatal  without  producing  any 
morbid  appearance  that  can  be  detected  on  dissection.”  And  he  refers 
to  a  case  related  by  Boyer,  and  four  recorded  by  Frank,  in  confirmation 
of  this  remark. 

In  other  cases,  the  fatal  result  may  be  occasioned  by  direct  and  de¬ 
monstrable  injury  of  the  spine  or  cord.  There  appear  to  be  three  forms 
of  lesion  that  will  lead  to  death  in  spinal  concussion  from  direct  severe 
violence. 

1.  Hemorrhage  within  the  spinal  canal  may  occur :  a.  Between  the 
vertebrae  and  the  dura  mater;  h.  Between  the  membranes  and  the  cord; 
c.  In  both  situations.  In  these  respects,  intravertebral  extravasations 
resemble  closely  those  which  occur  as  the  result  of  injury  within  the 
cranium. 

2.  Laceration  of  the  pia  mater  and  hernia  of  the  cord  may  be  produced. 

3.  The  injury  may  be  followed  by  inflammation,  and,  perhaps,  suppu¬ 
ration  of  the  menino'es,  with  softeninoj  and  disintesfration  of  the  sub- 
stance  of  the  cord.  This  is,  doubtless,  of  an  acute  and  probably  inflam¬ 
matory  character. 

Concussion  of  the  spinal  cord  from  a  direct  and  severe  injury  of  the 
back  may  also  terminate  in  complete  recoveiy  after  a  longer  or  shorter 
time,  or  in  incomplete  recovery.  The  probability  of  the  termination  in 
recovery  does  not  depend  so  much  on  the  actual  severit}’’  of  the  imme¬ 
diate  symptoms  that  may  have  been  occasioned  by  the  accident,  as  on 
their  persistence.  If  they  continue  beyond  a  certain  time,  changes  will 
take  place  in  the  cord  and  its  membranes  which  are  incompatible  with 
the  proper  exercise  of  its  functions. 

Injuries  of  the  Vertebral  Column  in  Concussion. — In  concussion  of  the 
spinal  cord,  there  is,  in  addition  to  the  lesion  of  the  cord,  serious  injury 
inflicted  on  the  ligamentous  and  bony  structures  of  the  vertebral  column. 
This  injury,  however,  must  be  considered  as  an  accidental  complication, 
as  it  does  not  occasion,  or  even  aggravate,  the  mischief  done  to  the 
medulla.  Thus  the  ligaments  may  be  torn  through  so  as  to  allow  partial 
separation  of  contiguous  vertebrfe;  or,  a  vertebra  maybe  fractured,  but 
without  any  displacement  of  the  broken  fragments,  or  other  sign  by 
which  it  is  possible  during  life  to  determine  the  exact  amount  of  injury 
inflicted  on  the  parts  external  to  the  cord.  In  this  respect  injuries  of 
the  spine  closely  resemble  those  of  the  head ;  their  chief  importance 
depending  on  the  amount  of  injury  inflicted  upon  the  contained  parts. 
In  the  spine,  as  in  the  head,  it  will  sometimes  be  found  after  death  from 
what  appears  to  be,  and  in  reality  is,  simple  injuiy  of  the  nervous 
centres,  that  the  vertebral  column  in  the  one  case,  and  the  skull  in  the 
other,  have  suffered  an  amount  of  injury  unsuspected  during  life;  and 


488 


INJUKIES  OF  THE  SPINE. 


which,  though  it  may  not  in  any  way  have  determined  the  fatality  of  the 
•  results,  3^et  affords  conclusive  evidence  of  the  violence  to  which  the  parts 
have  been  subjected,  and  the  intensity  of  the  disorganizing  shock  that 
the}"  have  suffered. 

There  is,  however,  a  very  essential  difference  between  the  spine  and 
the  head.  A  simple  fracture  of  the  cranium  may  be  of  no  moment, 
except  so  far  as  the  violence  that  has  occasioned  it  may  have  influenced 
the  brain.  In  the  spine,  the  case  is  not  parallel ;  for,  as  the  vertebral 
column  is  the  centre  of  support  to  the  bod}",  its  influence  in  this  respect 
will  be  lost  when  it  is  broken ;  even  though  the  spinal  cord  may  not 
have  been  injured  b}^  the  edges  of  the  fractured  vertebrae,  but  simply  vio- 
lentl}"  and  fatally  concussed  by  the  same  force  that  broke  the  spine. 

Boyer  noticed  the  very  interesting  practical  fact,  that,  when  the  inter- 
spinous  ligaments  were  ruptured  in  consequence  of  forcible  flexion  of 
the  spine  forwards,  no  fatal  consequences  usually  ensued,  the  integrity 
of  the  parts  being  restored  b}^  rest ;  but  that,  when  the  ligamenta  sub- 
flava  were  torn  through,  and  the  arches  separated,  paraplegia  and  death 
followed.  This  he  attributed  to  stretching  of  the  spinal  cord.  Sir  C. 
Bell,  however,  with  great  acuteness,  has  pointed  out  the  error  of  this 
explanation,  and  states  that  “  it  is  the  progress  of  the  inflammation  to 
the  spinal  marrow,  and  not  the  pressure  or  the  extension  of  it,  which 
makes  these  cases  of  subluxation  and  breach  of  the  tube  fatal. There 
can  be  no  doubt  that  this  explanation  is  the  correct  one  ;  and  that,  when 
once  the  spinal  canal  is  forcibly  torn  open,  fatal  inflammation  will  spread 
to  the  meninges  and  to  the  medulla  itself 

Effects  of  Slight  Blows. — The  consideration  of  the  effects  that  may 
be  produced  on  the  spinal  cord  by  slight  bloius,  whether  applied  to  the 
back  or  to  a  distant  part  of  the  body,  has  long  arrested  the  attention  of 
observant  practitioners.  Abercrombie,  writing  in  1829,  says,  that 
chronic  inflammation  of  the  cord  and  its  membranes  may  supervene 
upon  veiy  slight  injuries  of  the  spine.”  He  sa^^s  also,  “  Eveiy  injury  of 
the  spine  should  be  considered  as  deserving  of  minute  attention.  The 
more  immediate  cause  of  anxiety  in  such  cases  is  inflammator}"  action, 
which  may  be  of  an  acute  or  chronic  kind  ;  and  we  have  seen  that  it  may 
advance  in  a  very  insidious  manner  even  after  injuries  that  were  of  so 
slight  a  kind  that  they  attracted  at  the  time  little  or  no  attention.” 
Nothing  can  be  clearer  and  more  i:)Ositive  than  this  statement.  These 
remarks  of  Abercrombie  are  confirmed  by  Ollivier,  b}"  Bell,  and  by  other 
writers  on  such  injuries. 

Concussion  from  Indirect  Violence. — There  is  a  class  of  cases 
of  an  extremely  insidious  and  protracted  character;  in  which  the  patient 
has  received  no  blow  or  injuiy  upon  the  head  or  spine,  but  the  whole 
system  has  had  a  severe  shake  or  shock,  in  consequence  of  wdiich  disease 
is  developed  in  the  spinal  cord,  perhaps  eventually  extending  to  the 
membranes  of  the  brain.  These  cases  are  more  frequent  in  railway  than 
in  other  injuries;  but  they  occasionally  occur  in  consequence  of  ordinary 
accidents. 

One  of  the  most  remarkable  circumstances  connected  with  injuries  of 
the  spinal  cord  is,  the  disproportion  between  the  accident  and  the  mis¬ 
chief  produced  thereby.  Not  only  do  most  serious,  progressive,  and 
persistent  symptoms  of  concussion  of  the  spinal  cord  often  develop 
themselves  after  apparently  slight  injuries,  but  frequentl}^  when  there  is 
no  sign  whatever  of  external  lesion.  The  shake  or  jar  inflicted  on  the 
spine  when  a  person  jumping  from  the  height  of  a  few  feet  comes  to  the 
ground  suddenly  and  heavily  on  his  heels  or  in  a  sitting  posture,  has 


COXCUSSIOX  FROM  INDIRECT  VIOLENCE. 


489 


been  well  known  to  Surgeons  as  a  not  uncommon  cause  of  spinal  weak¬ 
ness  and  debility.  It  is  the  same  in  railway  accidents  ;  the  shock  to 
which  the  patient  is  subjected  being  often  followed  by  a  train  of  slowly 
progressive  symptoms,  indicative  of  concussion  and  subsequent  irritation 
and  inflammation  of  the  cord  and  its  membranes. 

It  is  worthy  of  remark,  that  the  S3^mptoms  of  spinal  concussion 
seldom  occur  when  a  serious  injury  has  been  inflicted  on  one  of  the  limbs, 
unless  the  spine  itself  have  at  the  same  time  been  directly"  and  severely’’ 
struck.  A  person  who  by  any  ordinary  accident  has  one  of  his  limbs 
fractured  or  dislocated,  necessarily  sustains  a  y-ery  severe  shock  ;  but  it 
is  extremely"  rare  to  find  that  the  spinal  cord  or  the  brain  has  been 
injuriously  influenced.  It  would  appear  as  if  the  violence  of  the  shock 
expends  itself  in  the  production  of  the  fracture  or  the  dislocation,  and 
that  a  jar  of  the  more  delicate  nervous  structures  is  thus  avoided.  A 
familiar  illustration  of  this  is  afforded  in  the  injury  sustained  by  a  watch 
b}’  falling  on  the  ground.  A  watchmaker  once  told  me  that,  if  the  glass 
be  broken,  the  works  are  rarel}’’  damaged ;  if  the  glass  escape  unbroken, 
the  jar  of  the  fall  will  usuall}"  be  found  to  have  stopped  the  movement. 

IIow  these  jars,  shakes,  shocks,  or  concussions  of  the  spinal  cord 
directly  influence  its  action,  I  cannot  say  with  certaint3^  When  a  mag¬ 
net  is  struck  a  heav}^  blow  with  a  hammer,  the  magnetic  force  is  jarred, 
shaken,  or  concussed  out  of  the  iron.  So,  if  the  spine  be  badly  jarred, 
shaken,  or  concussed  by  a  blow  or  a  shock  of  an}-  kind  communicated 
to  the  bodj^,  we  find  that  the  nervous  force  is  to  a  certain  extent  shaken 
out  of  the  man,  and  that  he  has  in  some  wa}'-  lost  nervous  power.  What 
immediate  change,  if  any,  has  taken  place  in  the  nervous  structure  to 
occasion  that  effect,  we  no  more  know  than  what  change  happens  to  a 
magnet  when  struck. 

Secondary  Effects. — Whatever  may  be  the  nature  of  the  primary 
change  that  is  produced  in  the  spinal  cord  b}'  a  concussion,  the  Second- 
aiy  Effects  are  clearly  inflammatoiy,  and  are  identical  with  those  phe¬ 
nomena  that  have  been  described  by  Ollivier,  Abercrombie,  and  others, 
as  dependent  on  chronic  meningitis  of  the  cord,  and  subacute  m^’elitis. 

One  of  the  most  remarkable  phenomena  attendant  upon  this  class  of 
cases  is,  that  at  the  time  of  the  occurrence  of  the  injury  the  sufferer  is 
usuall}^  quite  unconscious  that  any  serious  accident  has  happened  to  him. 

The  period  of  the  supervention  of  the  more  serious,  persistent,  and 
positive  S3miptoms  of  spinal  lesion  will  vary  greatl3\  Most  commonl3^, 
after  the  first  and  immediate  effects  of  the  accident  have  passed  off,  there 
is  a  period  of  comparative  ease,  and  of  remission  of  the  s3’mptoms, 
during  which  the  patient  imagines  that  he  will  speedily  regain  his  health 
and  strength.  This  period  may  last  for  maiy^  weeks,  possibly  for  two 
or  three  months.  Although  there  is  often  this  long  interval  between  the 
time  of  the  occurrence  of  the  accident  and  the  supervention  of  the  more 
distressing  s3'mptoms,  it  will  be  found,  on  close  inquiry,  that  there  has 
never  been  an  interval  of  complete  restoration  to  health.  His  friends 
remark,  and  he  feels  that  “  he  is  not  the  man  he  was.”  He  has  lost 
bodily  energy,  mental  capacit3",  and  business  aptitude.  He  looks  ill  and 
worn;  often  becomes  irritable  and  easily  fatigued.  He  still  believes  that 
he  has  sustained  no  serious  or  permanent  hurt,  and  so  long  as  he  is  at 
rest,  he  will  feel  tolerably  well ;  but  any  attempt  at  ordinaiy  exertion  of 
bod3"  or  mind  brings  back  all  feelings  or  indications  of  nervous  j^rostra- 
tion  and  irritation  characteristic  of  these  injuries;  and  to  these  will 
gradually  be  superadded  the  more  serious  S3miptoms  which  evidentl3^ 
proceed  from  a  chronic  disease  of  the  cord  and  its  membranes.  After  a 


k! 


490  INJURIES  OF  THE  SPINE. 

lapse  of  several  months — from  three  to  six — the  patient  will  find  that  he 
is  slowly  but  gradually  becoming  worse,  and  he  then,  perhaps  for  the  first 
time,  becomes  aware  of  the  serious  and  deep-seated  injury  that  his  nerv¬ 
ous  system  has  sustained. 

The  countenance  is  usually  pallid,  livid,  and  has  a  peculiarly  careworn 
expression ;  the  patient  generally  looking  much  older  than  he  really  is, 
or  than  he  did  before  the  accident.  I  have  seen  one  instance  of  flushing 
of  the  face. 

The  thoughts  are  confused.  The  patient  cannot  concentrate  his  ideas 
so  as  to  carry  out  a  connected  line  of  argument ;  he  attempts  to  read, 
but  is  obliged  to  lay  aside  the  book  or  paper  after  a  few  minutes’  attempt 
at  perusal.  All  business  aptitude  is  lost ;  partly  from  impairment  of 
memoiy,  partly  from  confusion  of  thought  and  inability  to  concentrate 
ideas  for  a  sufficient  length  of  time.  The  temper  often  becomes  changed 
for  the  worse,  the  patient  being  fretful,  irritable,  and  in  some  way — diffi¬ 
cult  perhaps  to  define,  but  easily  appreciated  by  those  around  him — 
altered  in  character. 

The  sleejD  is  disturbed,  restless,  and  broken.  He  wakes  up  in  sudden 
alarm  ;  dreams  much;  the  dreams  are  distressing  and  horrible. 

The  head  is  usuall}"  of  its  natural  temperature,  but  sometimes  hot. 
The  patient  complains  of  various  uneasy  sensations  in  it ;  of  pain,  ten¬ 
sion,  weight,  or  throbbing;  of  giddiness;  of  a  confused  or  strained 
feeling  in  it ;  and  frequently  of  loud  and  incessant  noises,  described  as 
roaring,  rushing,  ringing,  singing,  sawing,  rumbling,  or  thundering. 
These  noises  vary  in  intensity  at  different  periods  of  the  day ;  but,  if 
once  they  occur,  they  are  never  entirely  absent,  and  are  a  source  of  great 
distress. 

The  organs  of  special  sense  usually  become  more  or  less  seriously 
affected.  They  become  sometimes  over-sensitive  and  irritable,  or  their 
functions  are  impaired  or  perverted.  In  many  cases  we  find  a  combina¬ 
tion  of  all  those  conditions  in  the  same  organ.  Vision  is  usually  affected 
in  various  wa3"s  and  in  very  different  degrees.  In  some  cases,  though 
rarely,  there  is  double  vision  and  perhaps  slight  strabismus.  In  others 
there  is  an  alteration  in  the  focal  length,  so  that  the  patient  has  to  use 
glasses,  or  to  change  those  which  he  has  previousl}"  worn.  The  patient 
cannot  read  for  more  than  a  few  minutes,  the  letters  running  into  one 
another.  More  commonly,  muscse  volitantes  and  spectra,  rings,  stars, 
flashes,  or  sparks — white,  colored,  or  flame-like — are  complained  of. 
The  e^’es  often  become  over-sensitive  to  light ;  and  this  intolerance  of 
light  may  amount  to  positive  photophobia.  It  gives  rise  to  a  habitually 
contracted  state  of  the  brows,  so  as  to  exclude  light  as  much  as  possi¬ 
ble  from  the  e^^es.  One  or  both  ej^es  may  be  thus  affected.  This  intol¬ 
erance  of  light  ma}"  be  associated  with  dimness  and  imperfection  of 
sight.  Vision  m&y  be  normal  in  one  e}’e,  but  impaired  seriousl}"  in  the 
other.  The  circulation  in  the  bottom  of  the  eye  is  visible  to  some 
patients.  The  hearing  may  be  variously  affected.  Xot  only  does  the 
patient  commonly  complain  of  the  noises  in  the  head  and  ears  that  have 
alread}^  been  described,  but  the  ears,  like  the  eyes,  maj"  be  over-sensi¬ 
tive  or  too  dull.  One  ear  is  frequently  over-sensitive,  whilst  the  other 
is  less  acute  than  it  was  before  the  accident.  The  relative  sensibility^  of 
the  ears  may  readily  be  measured  by-  the  distance  at  which  the  tick  of  a 
watch  may^  be  heard.  Loud  and  sudden  noises  are  peculiarly  distress¬ 
ing  to  these  patients.  Taste  and  smell  are  sometimes,  but  more  rarely, 
perverted. 

The  sense  of  touch  is  impaired.  The  patient  cannot  pick  up  a  pin. 


SECONDARY  EFFECTS  OF  CONCUSSION. 


491 


cannot  button  his  dress,  cannot  feel  the  difference  between  different  tex¬ 
tures,  as  cloth  and  velvet.  He  loses  the  sense  of  iveight^  and  cannot 
tell,  for  instance,  whether  a  sovereign  or  a  shilling  is  balanced  on  his 
finger.  S^jeech  is  rarely  affected.  The  attitude  is  stiff  and  unbending. 
The  patient  holds  himself  very  erect,  usually  walks  straight  forwards, 
as  if  afraid  or  unable  to  turn  to  either  side.  The  movements  of  the 
head  or  trunks  or  both,  do  not  possess  their  natural  freedom.  There 
ma}'-  be  pain  or  difficulty  in  moving  the  head  in  the  antero-posterior 
direction,  or  in  rotating  it ;  or  all  movements  may  be  attended  by  so 
much  pain  and  difficulty  that  the  patient  is  afraid  to  attempt  them,  and 
hence  keeps  the  head  in  an  attitude  of  immobility.  The  movements  of 
the  trunk  are  often  equally  restrained,  especially  in  the  lumbar  region. 
Flexion  forwards,  backwards,  or  sideways,  is  painful,  difficult,  and  may 
be  impossible ;  flexion  backwards  is  usually  most  complained  of  If 
the  patient  be  desired  to  stoop  and  pick  an3Thing  off  the  ground,  he 
will  not  be  able  to  do  so  in  the  usual  way,  but  bends  down  on  the  knee 
and  so  reaches  the  ground.  If  he  be  laid  horizontal!}^,  and  told  to  raise 
himself  into  the  sitting  posture,  without  the  use  of  his  hands,  he  will 
be  unable  to  do  it. 

The  state  of  the  spine  will  be  found  to  be  the  real  cause  of  these 
symptoms.  On  examining  it  by  pressure,  by  percussion,  or  b}^  the 
application  of  the  hot  sponge,  it  will  be  found  that  it  is  painful,  and  that 
its  sensibility  is  exalted  at  one,  two,  or  three  points.  These  are  usually 
the  upper  cervical,  the  middle  dorsal,  and  the  lumbar  regions.  The 
exact  vertebrm  that  are  affected  vary  necessaril}^  in  different  cases ;  but 
the  exalted  sensibility  alwa^'s  includes  two,  and  usually  three,  at  each 
of  these  points.  It  is  in  consequence  of  the  pain  that  is  occasioned  by 
any  movement  of  the  trunk  in  the  wa}"  of  flexion  or  rotation,  that  the 
spine  loses  its  natural  suppleness,  and  moves  as  a  whole,  as  if  cut  out 
of  one  solid  piece,  instead  of  with  its  usual  flexibility. 

The  movements  of  the  head  upon  the  upper  cervical  vertehrse  are 
variousl}’-  affected.  In  some  cases  the  head  moves  freel}"  in  all  direc¬ 
tions,  without  pain  or  stiffness.  In  other  cases,  the  greatest  agoii}^  is 
induced  if  the  Surgeon  take  the  head  between  his  hands  and  bend  it 
forwards  or  rotate  it ;  the  articulations  between  the  occipital  bone,  the 
atlas,  and  the  axis,  being  evidentl}'’  in  a  state  of  inflammatoiy  irritation. 
The  pain  is  usually  confined  to  the  vertebral  column,  and  does  not  extend 
be^’ond  the  transverse  processes.  But,  in  some  instances,  the  pain 
extends  widel}''  over  the  back  on  both  sides,  and  seems  to  correspond 
with  the  distribution  of  the  posterior  branches  of  the  dorsal  nerves.  In 
these  cases,  from  the  musculo-cutaneous  distribution  of  these  nerves,  the 
pain  is  superficial  and  cutaneous  as  well  as  deepl}^  seated. 

The  muscles  of  the  back  are  usually  unaffected ;  but  in  some  cases, 
where  the  muscular  branches  of  the  dorsal  nerves  are  affected,  they 
ma}"  become  veiy  irritable  and  spasmodically  contracted,  so  that  their 
outlines  are  veiy  distinct. 

The  gait  of  the  patient  is  characteristic.  He  walks  more  or  less 
unsteadil}’’,  generall}^  uses  a  stick,  or  if  deprived  of  that,  is  apt  to  lay 
his  hand  on  any  article  of  furniture  that  is  near  to  him,  with  the  view 
of  steadying  himself.  He  keeps  his  feet  somewhat  apart,  so  as  to 
increase  the  basis  of  support,  and  consequently  walks  in  a  straddling 
manner.  As  one  leg  is  often  weaker  than  the  other,  he  totters  some¬ 
what,  and  raises  one  foot  but  slightly  off  the  ground,  so  that  the  heel  is 
apt  to  touch.  He  seldom  drags  the  toe  ;  but,  as  he  walks  flat-footed  as 
it  were  on  one  side,  the  heel  drags.  This  peculiar  straddling,  tottering, 


492 


INJURIES  OF  THE  SPINE. 


unsteacl}"  gait,  with  the  spine  rigid,  the  head  erect,  and  looking  straight 
forwards,  gives  the  patient  the  aspect  of  a  man  who  walks  blindfolded. 
The  patient  cannot  generally  stand  equall}’-  well  on  either  foot.  One 
leg  usually  immediately  gives  way  under  him  if  he  attempts  to  stand 
on  it.  He  often  cannot  raise  himself  on  his  toes,  or  stand  on  them, 
without  immediately  tottering  forwards.  His  power  of  walking  is 
alwaj’s  very  limited ;  it  seldom  exceeds  half  a  mile  or  a  mile  at  the 
utmost.  He  cannot  ride,  even  if  much  in  the  habit  of  doing  so  before 
the  accident.  There  is  usually  considerable  difficulty  in  going  up  and 
down  stairs — more  difficulty  in  going  down  than  up.  The  patient  is 
obliged  to  support  himself  b}^  holding  on  to  the  balusters,  and  often 
brings  both  feet  together  on  the  same  step. 

A  sensation  as  of  a  cord  tied  round  the  ivaist,  with  occasional  spasm 
of  tlie  diaphragm,  giving  rise  to  a  catch  in  the  breathing,  or  hiccup,  is 
sometimes  met  with,  and  is  very  distressing  when  it  does  occur. 

The  nervous  power  of  the  limbs  will  be  found  to  be  variousl}"  modified, 
and  will  generall}’  be  so  to  very  different  degrees  in  the  diflerent  limbs. 
Sometimes  one  limb  onlv  is  affected :  in  other  cases  the  arm  and  leg:  on 
one  side,  or  both  legs  only,  or  the  arm  and  both  legs,  or  all  four  limbs,  are 
the  seat  of  uneasy  sensations.  There  is  the  greatest  possible  variety  in 
these  respects,  dependent  of  course  entirely  upon  the  degree  and  extent 
of  the  lesion  that  has  been  inflicted  upon  or  induced  in  the  spinal  cord. 
Sensation  or  motion  only  ma}’  be  affected ;  or  both  may  be  affected,  either 
alike  or  in  unequal  degrees.  Sensation  and  motion  may  both  be  seriously 
impaired  in  one  limb,  or  sensation  in  one  and  motion  in  another.  The 
paralysis  is  seldom  complete.  It  ma3'  become  so  in  the  more  advanced 
stages,  after  several  3’ears ;  but  for  the  flrst  3’ear  or  two  it  is  almost 
always  partial.  It  is  sometimes  incompletely  recovered  from,  especially 
so  far  as  sensation  is  concerned. 

The  loss  of  motor  power  is  especiall3^  marked  in  the  legs,  and  more 
often  in  the  extensor  than  in  the  flexor  muscles.  The  extensor  of  the 
great  toe  is  especialH  apt  to  suffer.  The  hand  and  arm  are  less  fre- 
quentl3’  the  seat  of  motor  power  than  the  leg  and  foot ;  but  the  muscles 
of  the  ball  of  the  thumb,  or  the  flexors  of  the  Angers,  ma3'  be  affected. 
The  loss  of  motor  power  in  the  foot  and  leg  is  best  tested  by  the  appli¬ 
cation  of  tlie  galvanic  current,  so  as  to  compare  the  irritabilit3'  of  the 
same  muscles  of  the  opposite  limbs.  The  electric  test  is  not  under  the 
influence  of  the  patient's  will ;  and  a  very  true  estimate  can  thus  be  made 
of  the  loss  of  contractilit3"  in  an3’  given  set  of  muscles.  The  loss  of 
motor  power  in  the  hand  is  best  tested  b3'  the  force  of  the  patient’s  grasp. 
This  ma3"  be  roughl3"  estimated  by  telling  him  to  squeeze  the  Surgeon’s 
Angers,  first  with  one  hand  and  then  with  the  other,  or  more  accurately 
b3"  means  of  the  d3mamometer,  which  shows  on  an  index  the  precise  amount 
of  pressure  exercised  in  grasping.  It  is  in  consequence  of  the  diminution 
of  motor  power  in  the  legs  that  those  peculiarities  of  gait  which  have 
been  above  described  are  met  with,  and  the3^  are  most  marked  when  the 
amount  of  loss  is  unequal  in  the  two  limbs. 

Modi f  cation  or  diminution  of  sensation  in  the  limbs  is  one  of  the  most 
marked  phenomena  in  these  cases.  In  man3"  instances  the  sensibilit3^  is 
a  good  deal  augmented,  especiall3^  in  the  earlier  stages.  The  patient 
complains  of  shooting  pains  down  the  limbs,  like  stabs,  darts,  or  elec¬ 
trical  shocks.  The  surface  of  the  skin  is  sometimes  oversensitive  in 
places  on  the  back  ;  or  in  various  parts  of  the  limbs,  hot,  burning  sensa¬ 
tions  are  experienced.  After  a  time  these  sensations  give  place  to  various 
others,  which  are  very  differenth'  described  b3’'  patients.  Tingling,  a 
feeling  of  “  pins  and  needles,”  a  heavy  sensation,  as  if  the  limb  were 


SECONDARY  EFFECTS  OF  CONCUSSION. 


493 


asleep,  creeping  sensations  down  the  back  and  along  the  nerves,  and  for¬ 
mication,  are  all  commonlj"  complained  of.  These  sensations  are  often 
confined  to  one  nerve  in  a  limb,  as  the  ulnar  or  the  musculo-spiral. 
Numbness,  more  or  less  complete,  may  exist  independently  of,  or  be  asso¬ 
ciated  with,  all  these  various  modifications  of  sensation.  It  may  be  con¬ 
fined  to  a  part  of  a  limb,  may  influence  the  whole  of  it,  or  ma}"  extend  to 
several  limbs.  Its  degree  and  extent  are  best  tested  by  Brown-Sequard’s 
instrument. 

Coldness  of  one  of  the  extremities,  dependent  upon  loss  of  nervous 
power  and  defective  nutrition,  is  often  perceptible  to  the  touch,  and  may 
be  determined  bj’  the  thermometer;  but  in  many  cases  the  sensation  of 
coldness  is  far  greater  to  the  patient  than  it  is  to  the  Surgeon’s  hand, 
and  not  unfrequentl3'  no  appreciable  difference  in  the  temperature  of  two 
limbs  can  be  determined  b}^  the  most  delicate  clinical  thermometer, 
although  the  patient  experiences  a  veiy  distinct  and  distressing  sense  of 
coldness  in  one  limb. 

The  condition  of  the  limbs  as  to  size,  and  the  state  of  their  muscles, 
will  vary  greath^  In  some  cases  of  complete  paraplegia,  which  has 
lasted  for  3'ears,  it  has  been  remarked  that  no  diminution  whatever  has 
taken  place  in  the  size  of  the  limbs.  It  is  evident,  therefore,  that  loss 
of  size  in  a  limb  that  is  more  or  less  completelj'  paralj’zed  is  not  the 
simple  consequence  of  the  disuse  of  the  muscles ;  or  it  would  always 
occur.  But  it  must  arise  from  some  modification  of  innervation,  influ¬ 
encing  the  nutrition  of  the  limb,  independent!}'  of  the  loss  of  its  muscular 
activity.  In  most  cases,  however,  w'here  the  paral^’tic  condition  has  been 
of  some  duration,  the  limb,  on  accurate  measurement,  will  be  found  to 
be  somewhat  smaller  in  circumference  than  its  fellow  on  the  opposite 
side.  Most  commonly  when  a  limb  dwindles  the  muscles  become  soft, 
and  the  intermuscular  spaces  more  distinct.  Occasional!}',  in  advanced 
cases,  some  contraction  and  rigidity  in  particular  muscles  set  in.  Thus 
the  flexors  of  the  little  and  ring  Angers,  the  extensors  of  the  great  toe, 
the  deltoid  or  the  muscles  of  the  calf,  may  all  become  more  or  less  rigid 
and  contracted. 

The  body  itself  generally  loses  weight ;  and  a  loss  of  weight,  when  the 
patient  is  rendered  inactive  by  a  semi-paralyzed  state,  and  takes  a  fair 
quantity  of  good  food,  which  he  digests  sufficiently  well,  may  usually  be 
taken  to  be  indicative  of  progressive  disease  in  the  nervous  system. 
When  the  progress  of  the  disease  has  been  arrested,  though  the  patient 
may  be  permanently  paralyzed,  a  considerable  increase  of  size  and  weight 
often  takes  place.  This  is  a  phenomenon  of  common  occurrence  in  ordi¬ 
nary  cases  of  paralysis  from  disease  of  the  brain. 

The  condition  of  the  genito-ur inary  organs  is  seldom  much  deranged 
in  the  cases  under  consideration.  Retention  of  urine  very  rarely  occurs. 
Sometimes  irritability  of  the  bladder  is  a  prominent  symptom.  The  urine 
generally  retains  its  acidity,  sometimes  markedly,  at  others  but  very 
slightly  so.  As  there  is  no  retention,  it  does  not  become  alkaline,  ammo- 
niacal,  or  otherwise  offensive.  The  sexual  desire  and  j^ower  are  usually 
greatly  impaired,  and  often  entirely  lost ;  not  invariably  so,  however. 
I  have  never  heard  priapism  complained  of. 

The  contractility  of  the  sphincter  ani  has  not,  in  any  case  which  I 
have  observed,  been  so  far  impaired  as  to  lead  to  involuntary  escape  of 
flatus  or  of  feces. 

The  pulse  varies  in  frequency  at  different  periods.  In  the  early  stages 
it  is  usually  slow ;  in  the  more  advanced  it  is  quick,  near  to,  or  above 
100.  It  is  always  feeble. 


494 


INJUKIES  OF  THE  SPINE. 


The  P^'ogressive  Development  of  the  various  symptoms  that  have  just 
been  detailed  usually  extends  over  a  lenothened  period.  In  the  early 
stages,  the  chief  complaint  is  a  sensation  of  lassitude,  weariness,  and 
inability  for  mental  and  physical  exertion.  Then  come  the  pains,  ting- 
lings,  and  numbness  of  the  limbs ;  next  the  fixed  pain  and  rigidity  of 
the  spine;  then  the  mental  confusion  and  signs  of  cerebral  disturbance, 
and  the  affection  of  the  organs  of  sense ;  the  loss  of  motor  power,  and 
the  peculiarity  of  gait. 

It  is  by  this  chain  of  symptoms,  which,  though  fiuctuating  in  intensity, 
is  yet  continuous  and  unbroken,  that  the  injury  sustained,  and  the  ill¬ 
ness  subsequently  developed,  can  be  -linked  together  in  the  relation  of 
cause  and  effect. 

Pathological  Conditions. — Two  distinct  forms  of  chronic  and  sub¬ 
acute  infiammation  may  affect  the  contents  of  the  spinal  canal,  as  the 
results  of  injury  or  of  disease;  viz..  Inflammation  of  the  Membranes,  and 
Inflammation  of  the  Cord  itself. 

In  Spinal  Meningitis^  the  usual  signs  of  inflammatory  action  in  the 
form  of  vascularization  of  the  membranes  is  met  with.  The  meningo- 
rachidian  veins  are  turgid  with  blood,  and  the  vessels  of  the  pia  mater 
are  much  injected,  sometimes  in  patches ;  at  other  times  uniformly. 
Serous  fluid,  reddened  and  clear,  or  opaque  from  the  admixture  of  lymph, 
may  be  found  largely  effused  in  the  cavity  of  the  arachnoid.  In  dis¬ 
tinguishing  the  various  pathological  appearances  presented  by  fatal  cases 
of  chronic  spinal  meningitis,  Ollivier  makes  the  very  important  remark 
that  spinal  meningitis  rarely  exists  without  there  being  at  the  same  time 
a  more  or  less  extensive  inflammation  of  the  cerebral  meninges ;  and 
hence,  he  says,  arises  the  difficulty  of  determining  with  precision  the 
symptoms  that  are  special  to  inflammation  of  the  membranes  of  the  spinal 
cord. 

When  Myelitis  occurs,  the  inflammation  attacking  the  substance  of 
the  cord  itself,  the  most  usual  pathological  condition  met  with  is  soften¬ 
ing,  with  more  or  less  disorganization.  This  softening  of  the  cord  as  a 
consequence  of  inflammation,  may  occupy  very  varying  extents.  Some¬ 
times  the  whole  thickness  of  the  cord  is  affected  atone  point,  sometimes 
one  of  the  lateral  halves  in  a  vertical  direction ;  at  other  times  the  dis¬ 
ease  is  most  marked  in  or  wholly  confined  to  its  anterior  or  its  posterior 
aspect ;  or  the  gray  central  portion  may  be  more  affected  than  the  cir¬ 
cumferential  part.  Again,  these  changes  of  structure  may  be  limited  to 
one  part  only,  to  the  cervical,  the  dorsal,  or  the  lumbar.  It  is  very 
rarely  indeed  that  the  whole  length  of  the  cord  is  affected.  The  most 
common  seat  of  inflammatory  softening  is  the  lumbar  region ;  next  in 
order  of  frequency  the  cervical.  In  very  chronic  cases  of  myelitis,  the 
whole  of  the  nervous  substance  disappears,  and  nothing  but  connective 
tissue  is  left  at  the  part  affected.  Ollivier  observes  that,  when  myelitis 
is  consecutive  to  meningitis  of  the  cord,  the  inflammatory  softening  may 
be  confined  to  the  white  substance. 

Though  softening  is  the  ordinary  change  that  takes  place  in  a  cord 
that  has  been  the  seat  of  chronic  inflammation,  sometimes  the  nervous 
substance  becomes  increased  in  bulk,  more  solid  than  natural,  and  of  a 
dull  white  color,  like  boiled  white  of  egg.  This  induration  may  coexist 
with  spinal  meningitis,  with  congestion,  and  increased  vascularization 
of  the  membranes. 

It  is  important  to  observe  that,  although  spinal  meningitis  and  myelitis 
are  occasionally  met  with  distinct  and  separate,  yet  they  most  frequently 
coexist.  When  existing  together,  and  even  arising  from  the  same  cause. 


DIAGNOSIS  IN  SPINAL  CONCUSSION. 


495 


they  may  be  associated  in  very  varjdng  degrees.  In  some  cases  the 
symptoms  of  meningitis,  in  others  those  of  myelytis,  are  most  marked ; 
and,  after  death,  corresponding  characteristic  appearances  are  found. 

Diagnosis. — There  are  three  morbid  states,  with  one  or  other  of 
which  the  symptoms  of  spinal  concussion,  wdiich  have  been  just  de¬ 
scribed,  have  sometimes  been  confounded,  and  from  which  it  is  necessary 
to  diagnose  it.  These  are,  1.  The  Secondaiy  Consequences  of  Cerebral 
Concussion  ;  2.  Rheumatism ;  and  3.  Hysteria. 

1.  From  the  secondary  effects  of  cerebral  concussion  it  is  not  difficult 
to  diagnose  the  consequences  of  concussion  of  the  spinal  cord,  in  those 
cases  in  which  the  mischief  is  limited  to  the  vertebral  column.  The 
tenderness  and  rigidity  of  the  spine,  the  pain  on  pressing  upon  or  on 
moving  it  in  any  direction,  and  the  absence  of  any  distinct  lesion  about 
the  head,  will  sufficiently  mark  the  precise  situation  of  the  injury. 

The  two  conditions  of  cerebral  and  spinal  concussion  often  coexist 
primarily.  The  shock  that  jars  injuriousl}^  one  portion  of  the  nervous 
S3^stem,  very  commonly  produces  a  corresponding  effect  on  the  whole  of 
it,  on  the  brain  as  well  as  on  the  cord ;  and  the  secondary  inflammations 
of  the  spine,  which  follow  the  concussion,  even  when  that  is  primarily 
limited  to  the  vertebral  column  and  its  contents,  have  a  tendency  to  extend 
along  the  continuous  fibrous  and  serous  membranes  to  the  interior  of  the 
cranium,  and  thus  to  give  rise  to  symptoms  of  cerebral  irritation. 

2.  From  rheumatism  the  diagnosis  may  not  be  always  eas}",  especially 
in  the  earlier  stages  of  the  disease,  when  the  concussion  of  the  spine  and 
the  consecutive  meningitis  have  developed  pain  along  the  course  of  the 
nerves,  and  increased  cutaneous  sensibility’'  at  points.  By  attention, 
however,  to  the  history  of  the  case,  the  gradually  progressive  character 
of  the  sy^mptoms  of  spinal  concussion,  the  absence  of  all  fixed  pain  except 
at  one  or  more  points  in  the  back,  the  cerebral  complications,  the  gradual 
occurrence  of  loss  of  sensibility^,  of  tinglings  and  formications,  the  slow 
supervention  of  impairment  or  loss  of  motor  power  in  certain  sets  of 
muscles  (symptoms  that  do  not  occur  in  rheumatism),  the  diagnosis  will 
be  rendered  comparatively  easy” ;  the  more  so,  when  we  observe  that  in 
spinal  concussion  there  is  never  any  concomitant  articular  inflammation, 
and  that,  although  the  urine  may  continue  acid,  it  does'  not  usually 
show  a  superabundance  of  lithates. 

8.  Hysteria  is  the  disease  for  which  I  have  more  frequently  seen  con¬ 
cussion  of  the  spine,  followed  by”  meningo-myelitis,  mistaken  ;  and  it  has 
alway's  appeared  extraordinary  to  me  that  so  great  an  error  of  diagnosis 
could  easily  be  made.  Hy’steria,  w'hether  in  its  emotional  or  its  local 
form,  is  a  disease  of  women  rather  than  of  men,  of  the  young  rather 
than  of  the  middle-aged  and  old,  of  people  of  an  excitable,  imaginative, 
or  emotional  disposition  rather  than  of  hard-headed,  active,  practical 
men  of  business.  It  is  a  disease  that  runs  no  definite  or  progressive 
course,  that  assumes  no  permanence  of  action,  that  is  ever  varying  in 
the  intensity^,  in  the  degree,  and  in  the  nature  of  its  symptoms :  that  is 
marked  by”  excessive  and  violent  outbreaks  of  an  emotional  character, 
or  by  severe  exacerbations  of  its  local  symptoms,  but  that  is  equally 
characterized  by”  long-continued  and  complete  intermissions  of  its  various 
phenomena.  This  in  no  way  resembles  what  we  see  in  concussion  of  the 
spinal  cord,  or  in  the  consecutive  meningo-myelitis  ;  and  it  seems  to  me 
quite  unreasonable  to  call  a  case  one  of  hysteria  in  w”hich  a  man  active  in 
mind,  accustomed  to  self-control,  addicted  to  business,  suddenly,  and  for 
the  first  time  in  his  life,  after  the  infliction  of  a  severe  shock,  finds  him¬ 
self  affected  by  a  train  of  symptoms  indicative  of  serious  and  deep-seated 


496 


INJUEIES  OF  THE  SPINE. 


injury  to  the  nervous  system.  In  reality,  there  can  be  but  little  difficulty 
in  establishing  the  diagnosis  between  chronic  meningo-myelitis  and  hyste¬ 
ria.  The  persistence  of  the  s3’'mptoms,  their  slow  development,  their 
progressive  increase  in  severity,  notwithstanding  occasional  fluctuations 
and  intermissions  in  intensity,  the  invariable  presence  of  more  or  less 
paralysis  of  sensation,  or  of  motion,  or  both,  will  easily  enable  the  Surgeon 
to  judge  of  the  true  nature  of  the  case.  That  mental  emotion  is  occa¬ 
sionally  manifested  by  an  unfortunate  individual  who  has  been  seriousl}^ 
injured  b}^  an  accident  which  tends  to  shake  his  whole  nervous  s^’-stem, 
can  scarcely  be  matter  of  surprise ;  but  the  term  “  hysteria,”  elastic  as 
it  is,  cannot,  it  appears  to  me,  be  strained  so  far  as  to  denote  this  condi¬ 
tion  ;  and  even  if  it  be  considered  applicable  to  the  patient’s  mental 
state,  it  can  in  no  way  be  looked  upon  as  the  cause  of  those  bodil}^ 
sutferings  and  disabilities  which  constitute  the  most  important  and 
serious  part  of  his  disease. 

Prognosis. — The  prognosis  of  concussion  of  the  spinal  cord  and  that 
of  the  consecutive  meningo-myelitis  is  a  question  of  extreme  interest  in 
a  medico-legal  point  of  view,  and  is  often  involved  in  much  difficult^^ 

The  prognosis  requires  to  be  made  with  regard,  first  to  the  life,  and 
secondly  to  the  health  of  the  patient.  So  far  as  life  is  concerned,  it  is 
only  in  cases  of  severe  and  direct  blows  upon  the  spine,  in  which  intra- 
spinal  hemorrhage  to  a  considerable  extent  has  occurred,  or  the  cord  or 
its  membranes  have  been  ruptured,  that  a  speedy  fatal  termination  may 
be  feared. 

In  some  of  the  cases  of  concussion  of  the  spine,  followed  by  chronic 
inflammation  of  the  membranes  and  of  the  cord  itself,-  death  majr  super¬ 
vene  after  several,  perhaps  three  or  four,  ^^ears  of  an  increasingly  progres¬ 
sive  breaking  down  of  the  general  health,  and  the  slow  extension  of  the 
paralytic  s^^mptoms.  I  have  heard  of  several  instances  in  which  concus¬ 
sion  of  the  spine  has  thus  proved  fatal  some  j^ears  after  the  occurrence 
of  the  accident. 

I  have  never  known  a  patient  recover  who  has  been  afflicted  by  con¬ 
vulsions,  progressive  paral^^sis  developing  itself,  and  the  case  ultimately 
proving  fatal.  Gore,  of  Bath,  informs  me  that  he  is  acquainted  with 
two  cases  which  proved  fatal  at  long  periods  of  time  after  the  accident, 
in  both  of  which  this  s^^mptom  was  present.  Concussion  of  the  spine 
may  prove  fatal :  first,  at  an  early  period  by  the  severity  of  the  direct 
injuiy ;  secondly,  at  a  more  remote  date  b}"  the  occurrence  of  inflamma¬ 
tion  of  the  cord  and  its  membranes  ;  and,  thirdl}^  after  a  lapse  of  several 
years,  by  the  slow  and  progressive  development  of  structural  changes  in 
the  cord  and  its  membranes. 

If  death  do  not  occur,  is  recovery  certain  ?  Is  there  no  mid  state 
between  a  fatal  result,  proximate  or  remote,  and  absolute  and  complete 
recoveiy  ? 

In  considering  the  question  of  recovery  after  concussion  of  the  spine, 
we  have  to  look  to  two  points  :  first,  the  recoveiy  from  the  primaiy  and 
direct  effects  of  the  injury;  and,  secondly,  the  recoveiy  from  the  secon¬ 
dary  and  remote  consequences.  There  can  be  no  doubt  that  recovery, 
entire  and  complete,  may  occur  in  a  case  of  concussion  of  the  spine,  when 
the  s^^mptoms  have  not  gone  beyond  the  primary  stage,  when  no  inflam¬ 
matory  action  of  the  cord  or  its  membranes  has  been  developed,  and 
most  particularly  when  the  patient  is  j-oung  and  healthy.  This  last 
condition  indeed  is  most  important.  A  liealthy  young  man  is  not  only 
less  likely  to  suflfer  from  a  severe  shock  to  the  s^^stem  from  a  fall  or 
railway  injuiy  than  one  more -advanced  in  life  ;  but,  if  he  do  suffer,  his 


PROGXOSIS  OF  SPINAL  CONCUSSION. 


497 


chance  of  ultimate  recovery  will  be  greater,  provided  alwaj^s  that  no 
secondary  and  organic  lesions  have  developed  themselves.  I  believe 
that  such  recover}'  is  more  likel}^  to  ensue  if  the  primary  and  direct 
symptoms  have  been  severe,  and  have  at  or  almost  immediately  after  the 
occurrence  of  the  accident  attained  to  their  full  intensity.  In  these  cases, 
under  proper  treatment  the  severity  of  the  symptoms  gradually  subsides, 
and,  week  by  week,  the  patient  feels  himself  stronger  and  better,  until, 
usually  in  from  three  to  six  months  at  the  utmost,  all  traces  of  the  injury 
have  disappeared. 

Incomplete  or  partial  recovery  is  not  unfrequent  in  cases  of  severe 
and  direct  injury  of  the  spine.  The  patient  slowly  recovers  up  to  a 
certain  point  and  then  remains  stationary,  with  some  impairment  of 
innervation  in  the  shape  of  partial  paral3^sis  of  sensation  or  of  motion, 
or  both,  usually  in  the  lower  limbs.  The  intellectual  faculties  or  the 
organs  of  sense  are  more  or  less  disturbed,  weakened  or  irritated,  the 
constitution  is  shattered,  and  the  patient  presents  a  prematurely  worn 
and  aged  look.  In  such  cases  structural  lesion  of  some  kind,  in  the 
membranes,  if  not  in  the  cord,  has  taken  place,  which  necessarily  must 
prevent  complete  recoveiy. 

When,  therefore,  we  find  a  patient  who,  after  the  receipt  of  a  severe 
injury  of  the  spine  by  which  the  cord  has  been  concussed,  presents  the 
primary  and  immediate  symptoms  of  that  condition,  we  may  entertain 
a  favorable  opinion  of  his  future  condition,  provided  there  be  a  progres¬ 
sive  amelioration  of  the  S3nnptoms,  and  no  evidence  of  the  development 
of  an}^  inflammation,  acute  or  chronic,  of  the  membranes  and  the  cord. 
But  our  opinion  as  to  his  ultimate  recovery  must  necessaril}"  be  very 
unfavorable  if  the  progress  of  amendment  cease  after  some  w^eeks  or 
months,  leaving  a  state  of  impaired  innervation  ;  the  more  so,  if  subse- 
quentl}"  to  the  primary  and  immediate  effect  of  the  injuiy,  s3unptoms  of 
meningo-m3'elitis  have  declared  themselves.  In  such  circumstances 
partial  restoration  to  health  ma}’’  be  looked  for,  but  complete  recovery 
is  not  possible. 

When  a  person  has  received  a  concussion  of  the  spinal  cord  from  a 
jar  or  shake  of  the  bod}^,  without  any  direct  blow  on  the  back,  or  perhaps 
on  an}^  other  part  of  the  body,  and  the  s3^mptoms  have  progressively 
developed  themselves,  the  prognosis  will  alwa3^s  be  very  unfavorable ; 
for  this  reason,  that,  as  the  injury  is  not  sufficient  of  itself  to  produce  a 
direct  and  immediate  lesion  of  the  cord,  an}'  s3'mptoms  that  subsequently 
appear  must  be  the  result  of  structural  changes  in  it  consequent  on  its 
inflamation ;  and  these  secondar}'  structural  changes,  being  incurable, 
must  to  a  greater  or  less  degree,  but  permanently,  iujuriousl}'  influence 
its  action.  For  the  same  reason,  the  occurrence  of  a  lengthened  interval, 
a  period  of  several  weeks  for  instance,  between  the  infliction  of  the 
injury  and  the  development  of  the  spinal  s3’mptoms,  is  peculiarl}'  unfa¬ 
vorable.  In  forming  an  opinion  as  to  the  patient’s  probable  future  state, 
it  is  of  far  less  importance  to  look  to  the  immediate  or  early  severity  of 
the  symptoms  than  to  their  progressive  and  insidious  development. 

The  time  that  the  s3'mptoms  have  lasted  is  necessarily  a  most  im¬ 
portant  matter  for  consideration.  When  they  have  been  of  but  short 
duration,  they  may  possibly  be  dependent  on  conditions  that  are  com- 
pletel}^,  and  perhaps  easily,  removable  by  proper  treatment ;  for  instance, 
on  extravasation  of  blood,  or  on  acute  serous  inflammatory  effusion. 
But  when  the  symptoms,  however  slight  they  may  be,  have  continued 
even  without  progressive  increase,  but  have  merely  remained  stationary 
for  a  lengthened  period  of  man}'  months,  they  will  undoubtedly  be 
VOL.  I _ 32 


498 


INJUEIES  OF  THE  SPINE. 


found  to  be  dependent  on  those  secondary  structural  changes  that  follow 
inflammatory  action.  I  have  never  known  a  patient  to  recover  entirely, 
so  as  to  be  in  the  same  state  of  health  that  he  enjoj'ed  before  the  acci¬ 
dent,  in  whom  the  symptoms  dependent  on  chronic  inflammation  of  the 
cord  and  its  membranes,  and  on  their  consecutive  structural  lesions,  had 
existed  for  twelve  months.  And  though,  as  Ollivier  has  observed,  such 
a  patient  may  live  for  fifteen  or  twenty  years  in  a  broken  state  of  health, 
the  probability  is  that  he  will  die  within  three  or  four.  There  is  no 
structure  of  the  body  in  which  an  organic  lesion  is  recovered  from  with 
so  much  difficulty  and  with  so  great  a  tendency  to  resulting  impairment 
of  function,  as  the  spinal  cord  and  brain.  And,  with  the  exception 
probably  of  the  eye,  there  is  no  part  of  the  bod^^  in  which  a  slight  per¬ 
manent  change  of  structure  produces  such  serious  disturbance  of  func¬ 
tion  as  in  the  spinal  cord. 

Treatment. — The  general  principles  of  treatment  of  concussion  of 
the  spinal  cord  are  the  same,  from  whatever  cause  the  injury  may  have 
arisen. 

In  the  Early  Stages  of  a  case  of  Concussion  of  the  Spine ^  the  first 
thing  to  be  done  is  undoubtedly  to  give  the  injured  part  complete  and 
absolute  rest.  The  importance  of  rest  cannot  be  overestimated.  With¬ 
out  it,  no  other  treatment  is  of  the  slightest  avail ;  and  it  would  be  as 
rational  to  attempt  to  treat  an  injured  brain  or  a  sprained  ankle  without 
rest,  as  to  benefit  a  patient  suffering  from  a  severe  concussion  or  wrench 
of  the  spine  unless  he  be  kept  quiet.  It  is  the  more  important  to  insist 
upon  absolute  and  entire  rest,  for  the  reason,  that  not  unfrequently 
patients  feel  for  a  time  benefited  by  movement ;  and  hence  changes  of 
air  and  scene  are  thought  to  be  permanently  beneficial.  But  nothingcan 
be  more  erroneous  than  this  idea,  for  the  patient  will  invariably  be  found 
to  fall  back  into  a  worse  state  than  had  previously  existed.  In  more 
advanced  stages  of  the  disease,  when  chronic  meningitis  has  set  in, 
the  patient  suffers  so  severely  Horn  any,  even  the  very  slightest  move¬ 
ment  of  the  body,  that  he  instinctively  preserves  the  rest  which  is 
needed. 

In  order  to  secure  rest  efficientljq  the  patient  should  be  made  to  lie 
prone  on  a  couch.  In  the  prone  attitude,  the  spine  is  the  highest  part 
of  the  body;  thus  passive  venous  congestion  and  determination  of  blood, 
which  are  favored  when  the  patient  lies  on  his  back,  are  entirely  prevented. 
Again,  the  absence  of  pressure  upon  the  back  is  a  great  comfort  when 
it  is  unduly  sensitive  and  tender,  and  is  a  source  of  additional  safety  to 
the  patient,  if  he  be  paraplegic,  by  lessening  the  liability  to  the  forma¬ 
tion  of  bed-sores.  Lastly,  the  prone  position  presents  this  advantage 
over  the  supine,  that  it  allows  the  ready  application  of  local  treatment 
to  the  spine.  In  some  instances  complete  and  absolute  rest  may 'be 
secured  to  the  injured  spine  by  the  application  of  a  gutta-percha  case  to 
the  back,  embracing  the  shoulders,  nape,  and  back  of  the  head ;  or  by 
letting  the  patient  wear  a  stiff  collar,  so  as  to  give  support  to  the  neck. 

But,  if  rest  is  needed  to  the  spine,  it  is  equally  so  to  the  brain.  In 
cases  of  concussion  of  the  spine  the  membranes  of  the  brain  become 
liable  to  the  extension  of  infiammatory  action  to  them.  The  irritability 
of  the  senses  of  sight  and  hearing,  that  is  very  marked  in  many  of  these 
cases,  with  perhaps  heat  of  head  or  fiushings  of  the  face,  give  the  best 
evidence  of  this  morbid  action.  For  the  subdual  of  this  state  of  in¬ 
creased  cerebral  excitement  and  irritability,  it  is  absolutely  necessary 
that  the  mind  should  be  kept  as  much  as  possible  at  rest.  The  patient, 
feeling  himself  unequal  to  the  fatigue  of  business,  becomes  conscious 


TREATMENT  OF  SPINAL  CONCUSSION. 


499 


of  the  necessity  of  relinquishing  it,  though  not  perhaps  without  great 
reluctance,  and  until  after  many  ineffectual  efforts  to  attend  to  it. 
There  are  two  remedies  which  may  be  employed  with  much  advantage 
in  the  earlier  stages  of  spinal  concussion,  with  the  view  of  soothing  the 
irritation  of  the  nervous  system.  One  is  chloral,  to  procure  sleep ;  the 
other,  bromide  of  potassium,  to  allay  irritability. 

During  the  early  period  of  concussion  of  the  spine,  much  advantage  will 
usually  be  derived  from  dry  cupping  along  the  back  on  each  side  of  the 
vertebral  column.  In  some  cases  I  have  seen  good  effects  follow  the 
application  of  ice-bags  to  the  injured  part  of  the  spine.  At  this  period, 
I  believe,  medicine  is  of  little  service,  beyond  such  as  is  required  for  the 
regulation  of  the  general  health  on  ordinary  medical  principles. 

When  the  Secondary  Effects  of  Concussion  of  the  Spinal  Cord  have 
appeared,  much  may  often  be  done  not  only  for  the  mitigation  of  suffer¬ 
ing,  but  for  the  cure  of  the  patient,  by  carefully  conducted  local  and 
constitutional  treatment. 

Rest,  as  in  the  early  stages,  must  be  persevered  in;  but,  in  addition 
to  this,  counter-irritation  may  now  be  advantageously  employed.  The 
various  forms  in  which  this  means  is  familiar  to  the  Suro;eon — stimu- 
lating  embrocations,  mustard  poultices,  blisters,  and  setons  or  issues — 
may  be  successively  used. 

With  regard  to  internal  treatment,  I  know  no  remedy  in  the  early 
period  of  the  secondary  stage,  when  subacute  meningitis  is  beginning  to 
develop  itself,  that  exercises  so  marked  or  beneficial  an  influence  as  the 
bichloride  of  murcury  in  tincture  of  quinine  or  of  bark.  I  have  seen 
this  remedy  produce  the  most  beneficial  effects,  and  have  known  patients 
come  back  to  the  Hospital  to  ask  for  the  “bichloride”  as  the  only 
medicine  from  which  the}’^  had  derived  advantage.  At  a  more  advanced 
period,  and  in  some  constitutions  in  which  mercury  is  not  well  borne, 
the  iodide  or  the  bromide  of  potassium  in  full  doses  will  be  found  highly 
beneficial,  more  especially  when  there  are  indications  of  the  presence 
and  the  pressure  of  inflammatory  effusion. 

When  all  signs  of  inflammation  have  subsided — wdien  the  symptoms 
have  become  those  of  paralysis,  whether  of  sensation  or  of  motion — but 
more  especially  in  those  cases  in  which  there  is  a  loss  of  motor  power, 
with  a  generally  debilitated  and  cachectic  state,  cod-liver  oil,  strychnine, 
and  iron  may  be  advantageously  employed.  But  I  would  particularly 
caution  against  the  use  of  these  remedies,  and  more  especially  of  strych¬ 
nine,  in  all  those  cases  in  which  inflammation  is  still  existing,  or  during 
that  period  in  any  case  in  which  there  are  evidences  of  this  condition. 
In  such  circumstances  the  administration  of  strychnine  is  attended  by 
the  most  prejudicial  effects,  increasing  materially  and  rapidly  the  pa¬ 
tient’s  sufferings.  But  in  the  absence  of  inflammatory  irritation  it  will, 
if  properly  administered,  be  found  to  be  most  useful,  more  particularly 
in  restoring  lost  motor  power.  In  cases  in  which  strychnine  may  be 
advantageously  administered,  great  benefit  will  also  be  derived  from 
warm  salt-water  douches  to  the  spine,  and  galvanism  to  the  limbs. 

At  a  more  advanced  period,  when  general  cachexy  has  been  induced, 
and  more  or  less  paralysis  of  sensation  and  motion  continues  in  the 
limbs,  and  nothing  of  a  specific  nature  can  be  done  in  the  way  of  treat¬ 
ment,  our  whole  object  should  be  to  improve  the  general  health  on 
ordinary  medical  principles,  so  as  to  prevent  as  far  as  possible  the 
development  of  secondary  diseases,  such  as  phthisis  dependent  on 
malnutrition,  and  a  general  broken  state  of  health,  which  may  after 
several  years  lead  to  a  fatal  termination. 


500 


INJUKIES  OF  THE  SPIHE. 


WOUNDS  OF  THE  SPINAL  CORD. 

These  injuries  may  occur  from  stabs  with  pointed  instruments ;  from 
gunshot  violence ;  or,  most  frequently,  from  the  pressure  of  fractured 
vertebrae.  In  the  latter  form  of  injury  there  is  an  association  of  wound 
and  compression,  giving  rise  essentially  to  the  same  symptoms  as  if  the 
cord  were  divided. 

Symptoms. — W^hen  the  spinal  cord  is  completely  divided^  certain 
symptoms  occur  that  are  common  to  all  cases,  at  whatever  part  of  the 
cord  the  injury  has  been  inflicted,  provided  it  be  not  so  high  as  to  cause 
instant  death. 

In  the  first  place,  there  is  complete  paralysis  of  sense  and  motion  m 
all  the  parts  below  the  seat  of  injuiy,  though  the  mental  manifestations 
continue  intact.  The  precise  seat  of  injury  may  often  be  diagnosed  b^’’ 
the  extent  of  the  paralysis.  In  injury  of  the  lower  part  of  the  spine, 
there  may  be  paralysis  of  all  the  parts  supplied  by  the  nerves  of  the 
sacral  plexus,  whilst  those  from  the  lumbar  are  not  affected;  the  sensi¬ 
bility  being  lost  below  the  knees,  whilst  above  it  is  perfect — thus  leading 
to  the  inference  that  the  injury  has  been  inflicted  above  the  one  and 
below  the  other  set  of  nerves.  The  temperature  of  the  part  becomes 
lowered ;  though  in  some  cases,  when  the  paral3^sis  is  not  quite  com¬ 
plete,  the  reverse  has  been  observed;  and  after  a  time,  a  visible  diminu¬ 
tion  takes  place  in  its  nutritive  activity.,  the  circulation  becoming  feeble 
with  a  tendency  to  congestion  at  depending  points.  The  lessening  of 
nutritive  vigor  is  not  confined  to  the  paralyzed  parts,  but  affects  the 
whole  sj^stem,  the  patient  becoming  speedily  emaciated,  anaemic,  and 
cachectic.  The  skin  assumes  a  dirty  cadaverous  hue,  and  the  cuticle 
usually  exfoliates  in  branny  flakes. 

The  lowering  of  the  temperature,  the  disturbance  in  the  processes  of 
nutrition  and  secretion,  and  the  partial  supervention  of  emaciation  and 
cachexy,  are  dependent  upon  a  derangement  in  the  vaso-motor  influence 
exercised  bj^  the  spinal  cord.  This  derangement  does  not  altogether 
arise  from  the  simple  division  of  the  cord,  but  is  rather  the  consequence 
of  the  inflammation  set  up  in  it  and  its  membranes  by  the  injury,  and 
is  greatl}'  increased  by  all  conditions  that  aggravate  this :  thus  it  is 
more  marked  in  laceration  of  the  cord  and  its  continuous  irritation  by  a 
fractured  spine,  than  after  its  simple  division  with  a  cutting  instrument. 

The  general  symptoms  of  paralysis  following  injury  present  important 
modifications,  according  to  the  height  at  which  the  cord  is  divided. 

1.  When  the  injury  has  been  inflicted  in  the  Lumbar  or  Loiver  Dorsal 
Region.,  there  is  complete  paralysis  of  all  the  parts  supplied  by  the 
nerves  given  off  from  the  sacral  or  lumbar  plexuses,  or  both ; — of  the 
lower  extremities,  of  the  genital  organs,  and  of  the  trunk  as  high  as  the 
seat  of  injury.  There  is  always  relaxation  of  the  sphincter  ani,  with 
consequent  incontinence  of  flatus,  and,  to  a  great  extent  of  feces. 
There  is  at  first  retention  of  urine  in  consequence  of  the  paralysis  of 
the  bladder,  which  is  unable  to  expel  its  contents ;  after  a  time,  how¬ 
ever,  the  urine  dribbles  away  as  fast  as  it  is  poured  into  the  overdis¬ 
tended  organ,  the  neck  of  which  has  lost  its  contractile  sphincter-like 
action.  The  reason  wh}^  there  are  incontinence  of  feces  and  retention  of 
urine  in  these  cases,  is  this.  The  sphincter  ani  and  the  muscular  fibres 
of  the  bladder  are  both  voluntary  and  under  the  influence  of  the  spinal 
s^^stem.  When  paraplegia  exists,  the  restraining  power  of  the  sphincter 
ani  and  the  expelling  power  of  the  bladder  are  both  lost.  Hence  the 
bladder  cannot  expel  its  contents:  while  the  anus  cannot  retain  those 


EFFECTS  OF  WOUNDS  OF  THE  SPINAL  CORD.  501 


of  the  intestines,  which  are  brought  clown  to  it  by  the  peristaltic  move¬ 
ments  which  are  not  spinal,  but  under  the  influence  of  the  sympathetic 
nerve.  After  the  first  few  cla3^s  the  urine  becomes  ammoniacal  in  odor, 
and  alkaline  in  reaction.  This  is  probably  owing  to  changes  that  it 
undergoes  after  it  has  passed  into  the  bladder,  the  mucous  membrane  of 
which  becomes  chronically  inflamed,  secreting  a  viscid  alkaline  muco- 
pus,  which  mixes  with  the  urine.  In  the  early  stages  of  the  accident, 
the  penis  will  usually  be  observed  to  be  in  a  state  of  semi-erection. 
Patients  who  have  met  with  injuries  of  this  portion  of  the  spinal  cord 
ma}^  live  on  for  many  months,  and  even  for  a  year  or  two,  falling  into  a 
cachectic  state,  but  eventually  die,  usuall}’’  with  sloughing  of  the  nates, 
or  from  the  supervention  of  some  intercurrent  visceral  inflammation  of 
low  t^^pe. 

2.  When  the  cord  is  divided  in  the  Upper  Dorsal  Region^  about  the 
level  of  the  third  dorsal  vertebra,  we  have  not  onlj"  the  train  of  symptoms 
that  have  just  been  mentioned  as  characteristic  of  this  injuiy  lower  down, 
but  the  respiration  also  is  interfered  with  in  consequence  of  the  paraly¬ 
sis  of  the  greater  portion  of  the  expiratoiy  muscles.  The  intercostals, 
and  those  constituting  the  abdominal  wall,  no  longer  acting,  imperfect 
expiration  is  solely  effected  b}''  the  elasticity  of  the  walls  of  the  chest ; 
and  the  purely"  muscular  expiratory  movements,  such  as  sneezing  and 
coughing,  cannot  be  accomplished.  In  these  cases,  during  inspiration, 
which  is  effected  almost  exclusively  by  the  diaphragm,  the  ribs  are 
depressed  instead  of  being  expanded  and  raised  ;  and  the  abdominal 
wall,  which  is  soft  and  flaccid,  is  protruded  far  be^'ond  its  normal  limits. 
In  consequence  of  the  impediment  to  respiration  the  blood  is  not  pro- 
perl}^  arterialized,  and  slow  asph^^xia  goes  on,  usually  running  into  con¬ 
gestive  pneumonia,  and  terminating  fatally  in  about  a  fortnight  or  three 
weeks. 

3.  When  the  injury  is  situated  in  the  Lower  Cervical  Region,  not  only 
do  all  the  preceding  s^^mptoms  occur,  but  there  is  paralysis  of  the  upper 
extremities  as  well ;  and,  the  inspiration  being  entirely’  diaphragmatic, 
the  circulation  speedil}^  becomes  affected,  the  countenance  assuming  a 
suffused  and  purplish  look.  If  the  cord  have  been  divided  immediately 
above  the  brachial  plexus,  there  will  be  complete  paralysis  of  the  whole 
of  the  upper  extremities  ;  but  if  the  injury  be  opposite  the  sixth  cervical 
vertebra,  they  may  be  only  partially"  paralyzed.  This  happened  in  two 
cases  of  fracture  of  the  spine  in  this  region  that  were  some  ^'■eai’s  ago 
under  nw  care  at  the  Hospital.  In  both,  the  paral^^sis  existed  on  the 
ulnar  but  not  on  the  radial  side  of  the  arms,  owing  to  the  external  cuta¬ 
neous  and  radial  nerves  arising  higher  from  the  plexus  than  the  ulnar, 
and  thus  just  escaping  injuiy.  It  is  remarkable  that,  in  both  these  cases, 
there  was  acute  cutaneous  sensibility  in  the  arms  along  the  whole  line 
of  junction  between  the  paral^^zed  and  the  sound  parts.  In  cases  of 
injury  of  the  cord  in  this  situation,  death  usually  occurs  by  asphyxia 
in  the  course  of  a  week. 

4.  When  the  division  of  the  spinal  cord  takes  place  above  the  Origin 
of  the  Phrenic  Nerve  opposite  to  or  above  the  tliird  cervical  vertebra, 
instantaneous  death  results  from  the  paral}’sis  of  the  diaphragm,  as  well 
as  of  the  rest  of  the  respiratory  muscles,  inducing  sudden  asphyxia. 

It  necessarily'-  happens  in  partial  division  of  the  cord,  that  the  symp¬ 
toms  are  not  so  clearly^  marked  as  in  the  instances  that  have  just  been 
recorded.  Thus,  for  instance,  the  paralysis  may  not  extend  to  all  the 
parts  below  the  seat  of  injury;  it  may  be  attended  by  severe  pain  in 
some  of  the  semi-paralyzed  parts ;  or  motion  may  be  affected  in  one 


502 


INJURIES  OF  THE  SPINE. 


limb,  and  sensibility  in  another.  These  deviations  may  generally  be 
explained  by  some  peculiarity  in  the  seat  of  the  injury  to  the  cord,  or 
by  the  extent  of  its  division. 

MECHANICAL  INJURIES  OF  THE  VERTEBRAL  COLUMN. 

The  mechanical  injuries  to  which  the  vertebral  column  is  liable,  con¬ 
sist  of  Sprains  or  Wrenches,  Fracture,  and  Dislocation. 

Twists,  Sprains,  or  Wrenches  of  the  Spine,  without  fracture 
or  dislocation  of  the  vertebrae,  may  occur  in  a  variety  of  ways.  Boyer 
relates  a  fatal  case,  occurring  from  an  injury  received  in  practising  gym¬ 
nastics.  Sir  A.  Cooper  gives  an  instance  of  a  fatal  wrench  of  the  spine, 
from  a  rope  catching  a  boy  round  the  neck  while  swinging.  In  two  cases, 
the  injury  also  arose  from  violence  applied  to  the  cervical  spine;  in  one 
from  a  railway  accident,  in  the  other  from  a  fall  from  a  horse. 

These  wrenches  of  the  spine  are,  from  obvious  reasons,  most  liable  to 
occur  in  the  more  mobile  parts  of  the  vertebral  column,  as  the  neck  and 
loins  ;  less  frequently  in  the  dorsal  region. 

In  railway  collisions,  when  a  person  is  violently  and  suddenly  jolted 
from  one  side  of  the  carriage  to  the  other,  the  head  is  frequently  forcibly 
thrown  forwards  and  backwards,  moving  as  it  were  by  its  own  weight, 
the  patient  having  momentarily  lost  control  over  the  muscular  structure 
of  the  neck.  In  such  cases  the  patient  complains  of  a  severe  straining, 
aching  pain  in  the  articulations  between  the  head  and  the  spine,  and  in 
the  Cervical  Spine  itself.  This  pain  closely  resembles  that  met  with  in 
any  joint  after  a  severe  wrench  of  its  ligamentous  structures,  but  is  pecu¬ 
liarly  distressing  in  the  spine,  owing  to  the  extent  to  which  fibrous  tissue 
and  ligament  enter  into  the  composition  of  the  column.  It  is  greatly 
increased  by  to-and-fro  movements,  however  slight,  and  especially  by 
rotation  ;  also  by  pressure,  and  by  lifting  up  the  head  so  as  to  put  the 
tissue  on  the  stretch.  In  consequence  of  this,  the  patient  keeps  the  neck 
and  head  immovable,  rigid,  looking  straight  forwards.  He  cannot  raise 
his  head  off  a  pillow  without  the  assistance  of  his  hand,  or  that  of 
another  person. 

The  Lumbar  Spine  is  often  strained  in  railway  collisions,  with  or 
without  similar  injury  to  the  cervical  portion  of  the  column,  in  conse¬ 
quence  of  the  body  being  forcibly  swaj^ed  backwards  and  forwards  during 
the  oscillation  of  the  crrriage  on  the  receipt  of  a  powerful  shock.  In 
such  cases  the  same  kind  of  pain  is  complained  of.  There  is  the  same 
rigidly  inflexible  condition  of  the  spine,  with  tenderness  on  external 
pressure,  and  great  aggravation  of  sufiering  on  any  movement  being 
impressed  upon  it,  more  particularly  if  the  patient  bend  backwards. 
The  patient  is  unable  to  stoop ;  in  attempting  to  do  so,  he  alwa3^s  goes 
down  on  one  of  his  knees. 

These  strains  of  the  ligamentous  structures  of  the  spinal  column  are 
not  unfrequently  associated  with  some  of  the  most  serious  affections  of 
the  spinal  cord  that  are  met  with  in  surgical  practice  as  a  consequence  of 
injury.  They  ma\"  of  themselves  prove  most  serious,  or  even  fatal. 

The  Prognosis  will  depend  partly  on  the  extent  of  the  stretching  of 
the  muscular  and  ligamentous  structures,  partly  or  whether  there  is  any 
inflammatory  action  excited  in  them  which  ma}^  extend  to  the  interior  of 
the  spinal  canal.  As  a  general  rule,  where  muscular,  and  ligamentous 
structures  have  been  violently  stretched,  as  in  an  ordinary  sprain,  how¬ 
ever  severe,  the^^  recover  themselves  in  the  course  of  a  few  weeks,  or  at 
most  within  three  or  six  months.  If  a  joint,  as  the  shoulder  or  ankle. 


FRACTURE  OF  THE  SPINE. 


503 


continue  to  be  weak  and  perternaturally  mobile,  in  consequence  of  elon¬ 
gation  of  the  ligaments,  or  weakness  or  atrophy  of  the  muscles,  beyond 
this  period,  it  will,  in  all  probabilit}^  never  be  so  strong  as  it  was  before 
the  accident.  The  same  holds  good  with  the  spine  ;  and  a  vertebral 
column  which  has  been  so  weakened  as  to  require  artificial  support,  after 
several  months,  in  order  to  enable  it  to  maintain  the  weight  of  the  head, 
will  probably  never  regain  its  normal  strength. 

One  great  prospective  danger  in  strains  of  the  spine  is  the  possibility 
of  the  inflammation  developed  in  the  fibrous  structures  of  the  column 
extending  to  the  meninges  of  the  cord.  This  I  have  several  times  seen. 
It  is  particularly  apt  to  happen  when  the  strain  or  twist  occurs  between 
the  occiput  and  the  atlas  or  axis.  In  these  cases  a  rigid  tenderness  is 
gradually  developed,  which  is  most  distressing  and  persisting,  and  evi¬ 
dently  inflammatory.  Or  the  paralysis  may  be  confined  to  the  nerves 
that  are  connected  with  that  part  of  the  spine  that  is  the  seat  of  the 
wrench,  one  or  other  of  their  roots  either  having  suffered  lesion,  or  the 
nervous  cord  itself  having  been  injured  in  its  passage  through  the  inter¬ 
vertebral  foramen.  Lastl}^,  a  twist  of  the  spine  may  slowl}"  and  insidi¬ 
ously  be  followed  by  sjnnptoms  of  complete  paraplegia,  and  eventuall}'  b}' 
death  from  extravasation  of  blood  into  the  vertebral  canal. 

The  Treatment  of  these  injuries  is  the  same  as  that  of  concussion  of 
the  spinal  cord  (see  page  498). 

Fracture  of  the  Spine  ma}- occur  either  by  the  application  of  direct 
violence,  or  by  a  violent  twist  or  bend  of  the  bod}’  forwards.  Direct 
violence,  as  a  blow  or  gunshot  injury,  may  of  course  fracture  the  spine 
at  any  part  and  almost  to  any  extent,  in  some  cases  merely  detaching  a 
spinous  process,  in  others  splintering  and  comminuting  several  verte- 
brm  and  lacerating  or  dividing  the  spinal  cord.  Fracture  of  the  spine 
from  a  violent  but  forcible  bend  of  the  body  forwards  chiefly  occurs  in 
the  cervical  region.  It  is  usually  produced  by  a  person  falling  from  a 
height  on  the  head,  the  body  being  bent  forcibly  forward  so  as  to  drive 
the  chin  against  the  sternum.  This  accident  most  usually  happens  in 
falls  from  horseback,  or  in  a  person  taking  a  “  header”  into  shallow  water. 
In  some  cases  it  has  occurred  from  a  person  sitting  on  the  top  of  a  car¬ 
riage  having  the  head  forcibly  bent  down  whilst  passing  under  a  gate¬ 
way.  In  these  accidents  there  are  usually  extensive  rupture  of  the  spinal 
ligaments  and  displacement  of  the  bones,  as  well  as  fracture. 

The  extent  of  the  fracture  and  the  amount  of  displacement  necessarily 
vary  greatly.  The  spinous  process  merely  may  be  broken  off;  or  the 
arch  may  be  broken  through  on  each  side  of  the  spine ;  or  the  fracture 
may  extend  through  the  body  of  the  vertebra. 

In  some  cases  of  even  very  extensive  fracture  there  may  be  no  appre¬ 
ciable  displacement :  but  usually  some  change  of  position  ensues,  in 
many  cases  to  such  an  extent  as  to  compress  or  lacerate  the  spinal  cord. 
The  mode  of  occurrence  of  the  fracture  will  influence  the  amount  of  dis¬ 
placement.  If  the  fracture  be  through  the  arch,  or  consist  in  a  simple 
detachment  of  the  spinous  process  by  a  fall  or  a  blow  on  the  back,  there 
may  be  little  or  no  displacement.  If  it  occurs  from  gunshot  injury,  or 
from  a  fall  upon  the  head,  or  by  forcible  flexure  of  the  neck  and  body 
forwards,  as  when  the  body  is  compressed  between  the  top  of  a  carriage 
and  an  archway,  then  there  will  probably  be  great  displacement,  and  per¬ 
haps  separation  of  the  articulating  surfaces  of  contiguous  vertebrae. 

The  Signs  of  this  injury  vary  very  greatly,  and  depend  in  a  great 
degree  upon  the  extent  of  the  displacement.  If  this  be  inconsiderable, 
it  may  be  extremely  diflScult,  and  even  impossible  in  some  instances,  to 


504 


INJURIES  OF  THE  SPINE. 


pronounce  with  certainty  whether  the  spine  has  been  broken  or  not ; 
the  more  so,  if  the  fracture  do  not  implicate  the  body  of  the  vertebrae. 
If,  on  the  other  hand,  the  displacement  affect  the  axis  of  the  column  or 
compress  the  cord,  the  symptoms  are  so  marked  as  to  admit  of  easy 
diagnosis.  They  are  of  two  kinds  ;  those  presented  by  the  injury  of  the 
bone,  and  those  dependent  on  injury  by  compression  or  laceration,  or 
both,  of  the  spinal  cord. 

The  Local  Signs  are  usually  pain  at  the  seat  of  injury,  greatly  increased 
on  2)ressure  or  on  moving  the  j^art ;  inequality  of  the  line  of  the  spinous 
processes,  with  dejDression  of  the  upper  iDortion  of  the  sjnne,  and  cor¬ 
responding  2:»rominence  of  the  lower.  There  is  an  inability  to  siipj^ort 
the  body  in  the  erect  jDOsition,  and  to  move  the  spine  in  anyway  ;  hence, 
when  the  upper  joortion  of  the  column  is  injured,  the  j^atient  holds  his 
head  in  a  stiff  and  constrained  attitude,  fearing  to  turn  it  to  either  side. 

The  General  Symptoms  of  fracture  of  the  spine  are  dependent  upon 
the  injury  which  the  cord  has  received.  If  the  fracture  have  not  imiffi- 
cated  the  sj^inal  canal,  as  when  only  the  tip  of  a  spinous  i^rocess  has  been 
broken  off,  or  if  it  be  unattended  %  displacement,  although  it  may  tra¬ 
verse  the  bod}^  and  arches,  no  S3^m2Dtoms  depending  uj^on  injury  of  the 
cord  need  exist,  and  indeed  occasionally  the}’’  are  absent.  But  even  in 
these  cases  there  is  usually  some  paralysis,  owing  perhajDS  to  the  con¬ 
cussion  to  which  the  cord  has  been  subjected  at  the  moment  of  injury; 
and  occasionally  a  sudden  movement  by  the  patient  will  bring  on  dis- 
j^lacement,  by  which  the  cord  is  comjDressed  and  all  the  parts  below  the 
injured  spot  are  paral3^zed.  A  woman  was  admitted  into  IJniversity 
College  Hospital  with  an  injury  of  the  neck,  the  nature  of  which  could 
not  be  accuratel3"  ascertained.  She  was  in  no  way  paralyzed,  but  kept 
her  head  immovable  in  one  position.  A  few  da3"s  after  admission,  whilst 
making  a  movement  in  bed,  by  which  she  turned  her  head,  she  fell  back 
dead.  On  examination,  it  was  found  that  the  sjffnous  i^rocess  of  the  fifth 
cervical  vertebra  had  been  broken  off  short,  and  was  imj)acted  in  such  a 
wa3'  between  the  arches  of  this  and ’the  fourth  as  to  compress  the  cord. 
This  impaction  and  consequent  compression  probably  occurred  at  the 
time  of  the  incautious  movement,  thus  producing  immediate  death. 
When  there  is  only  partial  disjolaceraent,  there  may  be  but  incomplete 
I)aral3"sis  of  the  parts  below  the  injury;  of  one  arm,  one  leg,  etc.  In 
these  cases  there  is  usually  great  pain  at  the  seat  of  fracture,  and  extend¬ 
ing  from  it  along  the  line  of  junction  between  the  paralyzed  and  sound 
i:)arts  round  the  bod3"  or  along  the  limb.  This  S3^mptom,  which  is  of 
great  imj^ortance  as  exactly  defining  the  seat  of  injury,  is  due,  as  I 
found  in  dissecting  a  case  of  fracture  of  the  sixth  cervical  vertebra  under 
my  care,  to  the  fractured  bone  compressing  and  irritating  the  nerve  that 
issues  from  the  vertebral  notch  opposite  the  seat  of  injury. 

In  the  majority  of  cases  of  fracture  of  the  sj^ine  there  is,  however,  such 
displacement  of  the  bone  as  to  compress  the  whole  thickness  of  the  cord, 
and  thus  to  occasion  complete  paralysis.  This  paral3^sis  resembles  that 
wliich  arises  from  siraifie  division  of  the  cord,  but  is  followed  by  greater 
imioairment  of  nutrition,  as  shown  in  wasting  cachex3’,  a  tendency  to 
sloughing,  and  alkaline  urine.  The  reason  of  this  difference  is,  that  in 
fracture  the  cord  is  not  simply  com2:)ressed  or  divided,  but  is  continu- 
0USI3’'  irritated  b3^  the  edges  of  broken  bone,  and  thus  not  only  becomes 
incapable  of  any  healing  j^rocess,  but  is  kej^t  in  a  state  of  chronic  irrita¬ 
tion  and  inflammation. 

Prognosis. — Fractures  of  the  spine  through  the  bodies  of  the  vertebrae, 
with  disjelacement,  are  inevitably  fatal.  Death  occurs  in  three  different 


TREATMENT  OF  FRACTURED  SPINE. 


505 


wa3^s.  It  happens  priinaril}’’  and  instantaneously,  as  the  direct  and  im¬ 
mediate  consequence  of  the  injuiy,  in  all  those  cases  in  which  the  frac¬ 
ture  is  above  the  origin  of  the  phrenic  nerve.  It  occurs  secondaril}*  and 
indirectly,  at  a  more  or  less  remote  period,  as  the  result  of  changes  in 
the  bod}^  dependent  on  continued  loss  of  innervation,  in  all  cases  in  which 
the  injuiy  sustained  b}’’  the  cord  is  below  the  point  indicated  as  essential 
in  its  integrity  to  the  maintenance  of  life.  At  the  seat  of  injniy,  of  com¬ 
pression,  and  of  disorganization,  inflammation  is  necessarily"  developed  ; 
thence  it  spreads  along  the  membranes  and  in  the  cord  itself  to  a  varia¬ 
ble  distance,  giving  rise  to  effusion  in  the  canal  and  softening  of  the 
medulla.  It  is  doubtless  by  the  gradual  extension  upwards  of  these 
secondary  inflammatory  disorganizations,  that  death  is  ultimately  occa¬ 
sioned;  the  mischief,  when  low  down,  leading  to  impairment  of  the  actions 
dependent  upon  the  integrity  of  the  cord,  and  when  high  up  extending 
to  the  origins  of  the  phrenic  nerves  and  so  suspending  respiration. 

The  Treatment  of  these  injuries  is  sufficiently^  simple.  No  attempt  at 
reduction  can  of  course  be  made.  All  our  efforts  must  be  directed  to 
the  prolongation  of  life.  AYith  this  view,  if  the  fracture  be  in  such  a 
situation,  at  any  point  below  the  upper  dorsal  vertebrae,  for  instance,  as 
will  hold  out  a  prospect  of  life  being  prolonged  for  a  few^  weeks  or 
months,  means  must  be  taken  to  prevent  the  occurrence  of  sloughing  of 
the  nates,  an  accident  that  is  common,  and  usually  fatal  in  these  cases. 
The  patient  should  be  laid  at  once  on  a  water-bed,  cushion,  or  mattress; 
he  must  be  kept  scrupulously  clean,  and  his  urine  should  be  drawn  off 
twice  in  the  day  at  regular  hours.  If,  as  usually 
happens  after  a  time,  the  bowels  become  confined, 
relief  must  be  afforded  by  castor  oil  or  turpentine 
enemata.  A  nourishing  diet  must  be  administered, 
and  perfect  rest  in  one  position  enjoined.  In  this  way 
life  may  be  maintained  for  a  considerable  length  of 
time ;  and  ossific  union  of  the  fracture  may^  sometimes 
take  place,  though  the  patient  may  not  recover  from 
the  paraly^sis,  and  will  die  eventually  from  disease  of 
the  cord.  But  in  some  cases  a  much  more  satisfac¬ 
tory  result  is  obtained ;  the  patient  gradually  gains 
power  in  the  paraly^zed  parts.  In  these  cases  much 
assistance  will  be  afforded  him  bv  his  wearing  an 
apparatus  as  in  Fig.  201,  consisting  of  a  firm  pelvic 
band,  with  a  strong  iron  rod  shaped  to  the  spine,  and 
running  as  high  as  the  vertex,  having  padded  trans¬ 
verse  arms  to  support  the  head  and  shoulders,  and 
the  whole  attached  to  a  stout  leather  case  moulded 
to  the  back  and  shoulders. 

Trephining  the  Spine. — As  the  fatal  result  of  fracture  of  the  spine  is 
almost  inevitable,  and  as  it  is  undoubtedly  dependent  upon  the  compres¬ 
sion  or  division  of  the  cord  by  the  broken  vertebra,  the  idea  has  naturally 
suggested  itself  to  Surgeons  that  life  might  be  prolonged,  and  health 
perhaps  restored,  if  the  same  operation  were  extended  to  the  spine  which 
is  successfully"  employed  in  parallel  cases  of  injury  of  the  head:  viz.,  the 
elevation  and  removal,  if  necessary,  of  the  depressed  portion  of  the  bone. 
This  operation,  originally"  proposed  by  Heister,  was  first  performed  by 
Louis  and  Cline.  It  may  be  done  as  follows.  The  patient  lying  on  his 
face,  a  free  incision,  several  inches  in  length,  from  three  to  five,  according 
to  the  extent  of  tlie  injury",  is  made  along  the  line  of  the  spinous  pro¬ 
cesses,  and  the  muscular  masses  on  each  side  of  the  spine  are  dissected 


Fig.  201. 


Apparatus  for  Fracture  of 
Spine. 


506 


INJURIES  OF  THE  SPINE. 


awa}',  so  as  to  expose  the  osseous  surfaces.  The  spinous  processes,  at 
the  seat  of  injury,  should  then  be  successively  seized  with  strong  forceps, 
and  gently  but  firml}'  moved,  in  order  to  see  whether  there  be  fracture  at 
their  base  or  supporting  arches.  If  a  portion  of  bone  be  completel}'  broken 
off  it  may,  after  all  ligamentous  connections  have  been  severed,  be  raised 
b}^  the  forceps  or  an  elevator.  Should  one  arch  only  be  broken  through, 
the  uninjured  one  may  be  divided  by  cutting  pliers  or  a  Hey’s  saw ;  or, 
should  both  be  unbroken,  the  Surgeon  may,  if  he  think  it  prudent  to 
proceed  further,  divide  both  in  this  wa}’,  and  so  remove  them  and  the 
spinous  process,  exposing  the  theca  of  the  cord.  After  the  operation, 
the  wound  is  to  be  simply  dressed  and  the  patient  kept  in  the  prone 
position. 

The  results  of  this  operation  are  not  very  encouraging.  It  has  been 
performed  by  various  Surgeons  in  different  countries,  but  chiefly  in 
America,  about  thirt}^  times ;  and,  although  some  temporaiy  advantage 
seems  to  have  occurred  in  a  few  of  the  cases,  permanent  success  has  only 
been  obtained  in  one  instance  by  Gordon  of  Whitworth  Hospital,  Dublin. 
But,  though  so  far  the  result  has  been  but  little  satisfactory,  ought  Sur¬ 
geons  to  discard  the  operation  ?  I  think  not :  because,  as  fracture  of  the 
spine  with  serious  lesion  of  the  cord  cannot  be  recovered  from,  and  has 
an  almost  invariably  fatal  termination,  and  as  the  evil  consequences 
of  the  fracture  are  dependent  not  only  upon  the  priraaiy  lesion  of  the 
cord,  but  on  the  secondary  disorganizing  and  inflammatoiy  processes  set 
up  in  it  b}"  the  continued  irritation  of  the  fractured  fragments,  we  are 
justified  in  attempting  the  removal  of  this  source  of  certain  misery  and 
impending  death  b}'  the  only  means  in  our  power — operative  procedure; 
and  we  are  the  more  justified  in  this  course,  as  the  operation  is  not 
necessarily  dangerous,  does  not  appear  often  to  have  hastened  death,  and 
has  certainl}'',  in  some  cases,  afforded  most  marked  relief,  the  paralytic 
symptoms  disappearing  to  a  great  extent,  and  the  patient  being  able  to 
move  the  limbs  that  were  previousl}’  motionless. 

One  serious  objection  that  has  been  urged  against  the  operation  must 
not,  however,  be  overlooked.  It  is,  that  in  the  great  majority  of  cases 
the  fracture  of  a  vertebra  is  through  the  bodj^  and  not  through  the  arches. 
This  undoubtedl}"  is  so,  and  it  is  this  circumstance  that  has  rendered  the 
operation  as  3'et  little  more  that  a  means  of  giving  relief  when  the  cord 
is  partiall}-  divided  and  lacerated  b^"  being  stretched  over  a  rough  and 
jagged  edge  of  the  broken  bod}^  of  a  vertebra  thrust  back  against  it. 
Little  more  than  temporaiy  relief  can  be  expected  from  the  removal  of 
the  pressure  from  behind  ly  cutting  awa^^  the  arches.  But,  when  these 
portions  onl^^  of  the  spinal  column  are  fractured  and  displaced,  a  rare 
condition  it  is  true,  then  permanent  good  ma^"  be  expected  to  follow  the 
operation.  If  signs  of  such  injuiy  exist,  as  evidenced  b}’  distortion  or 
depression  of  one  or  more  spinous  processes,  it  would  most  certainl}"  be 
quite  proper  for  the  Surgeon  to  adopt  the  onlj"  means  in  his  power  of 
affording  relief.  The  principal  danger,  and  usual  cause  of  death  after 
cutting  awa}^  a  portion  of  the  spine  is,  undoubtedly^  either  the  con¬ 
tinuance  of  the  inflammation  excited  by  the  injury  in  the  cord  and  its 
membranes,  or  its  increase  or  development  by  the  operation  itself. 

Dislocations  of  the  Spine. — On  looking  at  the  arrangement  of  the 
articular  surfaces  of  the  vertebrae,  the  very  limited  motion  of  which  they 
are  susceptible,  and  the  way  in  which  they  are  closely  knit  together  by 
strong  ligaments  and  short  and  powerful  muscles,  it  is  obvious  that 
dislocations  of  these  bones  must  be  excessively’’  rare.  So  seldom,  indeed, 
do  they’^  occur  that  their  existence  has  been  denied  by  many  Surgeons. 


DISLOCATIONS  OF  THE  SPINE. 


507 


Yet  there  are  a  suflScient  number  of  instances  on  record  to  prove  that 
these  accidents  may  happen.  Those  cases  that  have  been  met  with  have 
usually  been  associated  with  partial  fracture,  but  this  complication  is 
not  necessary.  In  all,  the  displacement  was  incomplete ;  and,  indeed,  a 
complete  dislocation  cannot  occur. 

Dislocation  of  the  Atlas  from  the  Occipital  Bone  has  been  described 
in  two  instances  only — by  Lassus  and  Paletta.  In  the  case  by  Lassus, 
death  ensued  in  six  hours,  and  the  right  vertebral  artery  was  found  to 
be  ruptured.  In  the  other  case,  the  patient  is  said  to  have  lived  for  five 
da3"s,  but  the  report  is  so  incomplete  that  little  value  can  be  attached 
to  it. 

Dislocation  of  the  Axis  from  the  Atlas  is  of  more  frequent  occurrence. 
It  ma}"  happen  with  or  without  fracture  of  the  odontoid  process.  In 
either  case,  the  axis  is  carried  backwards  and  the  spinal  cord  thus  com¬ 
pressed.  This  accident  is  said  to  have  been  caused  b}^  a  person  in  play 
lifting  a  child  off  the  ground  by  its  head ;  the  combination  of  rotation 
and  traction  in  this  movement  being  especially  liable  to  occasion  the 
accident.  For  the  same  reason,  it  has  been  met  with  in  persons  executed 
b}'  hanging.  Death  w'ould  probably’  be  instantaneous  in  these  circum¬ 
stances.  It  has,  however,  been  stated  that,  in  dislocations  of  this  kind, 
life  has  been  saved  b}'  the  Surgeon  placing  his  knees  against  the  patient’s 
shoulders,  and  drawing  or  twisting  the  head  into  position.  This,  liow- 
ever,  I  cannot  believe  possible  if  the  displacement  have  been  complete, 
as  death  must  be  instantaneous,  the  cases  of  supposed  dislocation  and 
reduction  having  probably  been  instances  of  concussion  of  the  cord  with 
sprain,  of  the  neck. 

Dislocation  of  any  one  of  the  five  Lower  Cervical  Vertehrse  may 
occur.  The  third  vertebra  is  least  frequently  dislocated  ;  the  fifth  is 
more  commonly'  displaced.  These  injuries  are  usually  associated  with 
fracture ;  sometimes,  though  rarel}^,  the}^  happen  without  this  complica¬ 
tion.  In  these  dislocations,  as  in  those  that  have  alread^^  been  described, 
the  displaced  bone  carries  with  it  the  whole  of  that  portion  of  the  ver¬ 
tebral  column  which  is  above  it,  no  single  bone  being  dislocated  either 
among  those  above  or  those  below’  the  displacement. 

These  accidents  most  commonly  happen  from  forcible  fiexion  of  the 
neck  forwards,  though  traction  and  rotation  conjoined  have  occasioned 
them.  In  a  case  of  luxation  of  the  sixth  and  seventh  cervical  vertebrae, 
recorded  by  J.  Roux,  the  accident  happened  to  a  sailor  plunging  into 
the  sea  for  the  purpose  of  bathing,  and  coming  head  foremost  against  a 
sail  which  had  been  spread  out  to  prevent  the  attack  of  sharks ;  he  died 
on  the  fourth  da3^  In  a  patient  of  mine,  wdio  fell  out  of  a  wdndow  in 
such  a  wa^’  that  the  head  was  doubled  forwards  upon  the  chest,  and 
who  was  brought  to  the  Hospital  with  supposed  fracture  of  the  spine, 
we  found  after  death,  which  occurred  on  the  fifth  da}’,  that  the  seventh 
cervical  vertebra,  carrying  with  it  the  upper  portion  of  the  spine  and 
the  head,  had  been  dislocated  forwards  from  the  first  dorsal,  there  being 
a  wide  gap  posteriori}’  between  the  laminje  of  these  bones,  with  hori¬ 
zontal  splitting  of  the  intervertebral  substance,  detaching  with  it  an 
extremely  thin  and  small  layer  of  bone  from  the  body  of  the  seventh. 
There  was  no  fracture  about  the  articular  processes,  which  were  com¬ 
pletely  separated  from  one  another.  The  symptoms  of  these  accidents 
are  necessarily  excessively  obscure,  being  very  liable  to  be  confounded 
with  those  of  fracture.  Reduction  has  been  effected  in  a  sufficient  num¬ 
ber  of  cases  of  this  kind  to  justify  the  attempt  being  made  when  danger 
is  imminent. 


508  INJURIES  OF  THE  FACE  AND  ADJACENT  PARTS. 


Dislocation  of  the  Transverse  Process  of  these  Cervical  Vertehrse 
occasionally  occurs.  The  patient,  after  a  sudden  movement,  or  a  fall 
on  the  head,  feels  much  pain  and  stiffness  in  the  neck,  the  head  being 
fixed  immovably,  and  turned  to  the  opposite  side  to  that  on  which  the 
displacement  has  occurred.  In  these  cases  I  have  known  Reduction 
effected  by  the  Surgeon  placing  his  knees  against  the  patient’s  shoulders, 
drawing  on  the  head,  and  then  turning  it  into  position,  the  return  being 
effected  with  a  distinct  snap. 

In  the  Dorsal  Region^  dislocation  of  the  spine,  though  excessively 
rare,  may  occur ;  seldom,  however,  without  being  accompanied  by  frac¬ 
ture.  The  last  dorsal  vertebra  has  been  several  times  found  dislocated 
from  the  first  lumbar,  with  rupture  of  the  intervertebral  fibro-cartilage. 
In  these  cases,  however,  there  has  usually  been  found  fracture  of  the 
transverse  processes  of  the  first  lumbar  vertebra,  or,  as  in  an  instance 
recorded  by  Sir  C.  Bell,  fracture  of  its  bod}^ 

I  am  not  acquainted  with  any  case  in  which  dislocation  without  frac¬ 
ture  of  the  Lumbar  spine  has  been  observed. 


CHAPTER  XXYI. 

INJURIES  OF  THE  FACE  AND  ADJACENT  PARTS. 

Face. — Cuts  about  the  Cheeks  and  Forehead  are  of  common  occur¬ 
rence.  These  injuries  present  nothing  peculiar,  except  that  the  structures 
of  the  face  partake  of  the  same  tendenc}’’  to  ready  repair,  as  well  as  to 
the  supep'ention  of  erysipelatous  inflammation,  that  characterizes  the 
scalp  when  injured. 

In  the  Treatment  of  these  wounds,  it  is  of  much  consequence  to  leave 
as  little  scarring  as  possible.  The  edges,  after  being  well  cleaned,  should 
be  brought  neatly  into  apposition  by  fine  harelip  pins  and  twisted 
suture,  or  by  a  few  points  of  interrupted  suture ;  more  particularly  if 
the  wound  be  transverse,  and  implicate  the  lips  or  nose.  When  the 
wound  is  in  the  neighborhood  of  the  eyelids,  especial  care  must  be  taken 
to  prevent  any  loss  of  substance,  lest  the  contraction  of  the  cicatrix 
produce  eversion  of  the  lid.  In  those  cases  in  which  a  portion  of  the 
nose  or  lip  has  been  lost,  much  may  be  done  to  repair  the  deformity  by 
properl}^  conducted  plastic  operations,  such  as  will  be  described  in 
Chapter  LYIII.  The  bleeding,  whicli  is  usually  very  free  in  wounds  of 
the  face,  in  consequence  of  some  arterial  branch  having  been  divided, 
may  often  be  arrested  by  passing  the  harelip  pin  under  the  vessel,  and 
applying  the  twisted  suture  above  it,  so  that  it  may  be  compressed. 

If  the  Lip  he  cut  from  within^  by  being  struck  against  the  teeth,  the 
coronary  artery  may  be  divided,  the  patient  swallowing  the  blood  that 
flows  into  the  mouth.  Some  3^ears  ago,  a  man  was  brought  to  the  Hos¬ 
pital,  drunk,  and  much  bruised  about  the  face.  Shortly  after  his 
admission  he  vomited  a  large  quantity  of  blood,  which  was  at  first 
supposed  to  proceed  from  some  internal  injuiy;  but,  on  examining  his 
mouth,  it  was  found  that  the  blood  came  from  the  coronarj^  artery  of  the 
lip,  which  was  divided  with  the  mucous  membrane. 

Parotid  Duct. — It  occasionally  happens  in  wounds  or  abscesses  of 
the  cheek  that  the  parotid  duct  is  divided,  in  consequence  of  which  the 


INJURIES  OF  THE  NOSE  AND  EARS. 


509 


wound  does  not  close,  and  a  trickling  of  saliva  takes  place  upon  the 
outside  of  the  cheek,  so  as  to  establish  a  Salivary  Fistula^  a  source  of 
much  disfiofurement  and  inconvenience.  The  surface  surrounding  it  is 
puckered  and  somewhat  excoriated,  and  the  fistula  opens  by  a  granulat¬ 
ing  aperture. 

If  this  condition  be  recent,  a  cure  may  sometimes  be  accomplished, 
by  paring  the  edges  of  the  external  wound,  bringing  them  into  close 
apposition,  xind  appl3’ing  pressure  upon  the  part.  If  it  be  of  old  stand¬ 
ing,  the  probabilit}’’  is  that  the  aperture  into  the  mouth  is  closed,  and 
that  something  more  will  be  required  than  bringing  the  lips  of  the  wound 
together.  With  this  view,  the  operation  that  will  be  described  in  Chap¬ 
ter  LY.  must  be  had  recourse  to. 

Besides  the  fistula  of  the  Stenonian  duct,  other  fistulous  apertures 
may  take  place  in  the  cheek,  as  the  result  of  injuiy  or  disease,  allowing 
the  escape  of  a  small  quantit}"  of  saliva.  These  openings  are  always 
difficult  to  heal ;  the  edges  becoming  callous,  and  not  readily  taking  on 
reparative  action.  Closure  ma}"  be  effected  in  some  cases  by  cauteriza¬ 
tion  witli  nitrate  of  silver,  or  with  a  red-hot  wire,  due  attention  being 
paid  to  the  general  health.  In  other  cases,  the  electric  canter}’’  may 
prove  successful.  If,  however,  the  opening  be  free,  with  much  indurated 
structure  about  it,  it  may  be  necessary  to  excise  a  portion  of  the  edges 
before  bringing  them  together. 

o  o  O 


Nose. —  Foreign  Bodies^  such  as  pebbles,  beads,  dried  peas,  etc.,  are 
occasion  all}’’  met  with  in  the  nostrils  of  children,  having  been  stuffed  up 
in  pla}',  and  becoming  so  firml}’  fixed  as  to  require  extraction  b}^  the 
Surgeon.  For  this  purpose  a  pair  of  urethral  or  polypus  forceps  will 
usuall}"  be  found  convenient.  In  some  cases,  however,  a  bent  probe  or 
an  ear-scoop  will  remove  the  impacted  bod}^  most  easil}". 

The  Ears  are  not  unfrequently  wounded  in  injuries  of  the  head  and 
scalp ;  a  portion  of  the  external  ear  being  sometimes  torn  down  and 
hanging  over  the  side  of  the  face.  In  these  cases,  as  in  scalp-injuries, 
the  part  should  never  be  removed,  but,  however  lacerated 
and  contused,  should  be  cleaned  and  replaced  b}^  means  of  Fig.  203, 
a  few  points  of  suture  and  strips  of  plaster.  When  the  carti-  ^ 

laginous  portion  of  the  ear  is  divided,  nice  management  is 
usuall}"  required  in  effecting  perfect  union. 

Foreign  Bodies  are  often  pushed  into  the  ears  of  children 
in  play  with  one  another.  When  pointed  or  angular,  such 
as  pieces  of  stick,  the}^  ma}^  readil}^  be  extracted  with  for¬ 
ceps;  but  when  round  and  small,  such  as  pebbles  or  beads, 
the}^  are  not  so  easil}’^  removed. 

The  foreign  body  may  occasional!}’’  be  removed  by  passing 
the  bent  ear-scoop  around  it.  In  some  cases  I  have  found  an 
instrument  (Fig.  202)  made  by  Coxeter  on  the  model  of 
Civiale’s  urethral  scoop,  useful  in  extracting  a  foreign  body 
from  the  ear.  It  can  be  introduced  straight  and  then  passed 
beyond  it,  when,  by  the  action  of  a  screw  in  the  handle,  the 
scoop  is  curved  forwards,  and  so  enables  extraction  to  be 
readily  effected.  In  other  cases  the  foreign  body  is  best 
removed  by  forcibly  syringing  the  ear  with  tepid  water,  ^ 

injected  by  means  of  a  large  brass  syringe  in  a  full  stream, 
the  pinna  being  drawn  up  so  as  to  straighten  the  external  Ear-scoop. 
meatus.  In  this  way  the  bead  or  pebble  is  soon  washed  out 
by  the  reflux  of  the  water  striking  against  the  tympanum.  Should  these 
means  not  suffice,  it  is  better  to  leave  matters  alone,  and  to  allow  the 


fh. 


510  INJUKIES  OF  THE  FACE  AND  ADJACENT  PARTS. 


foreign  body  to  become  loosened,  than  to  poke  instruments  into  the  ear 
with  the  view  of  forcibly  extracting  it.  These  attempts  are  ill-advised; 
and  I  have  known  death  to  follow  prolonged  and  unsuccessful  efforts  for 
the  extraction  of  a  pebble  from  the  ear. 

Orbit. — Injuries  of  the  orbit  may  be  dangerous,  either  to  the  brain 
or  to  the  eye.  If  deep  and  directed  upwards,  they  are  always  serious,  on 
account  of  the  proximity  of  the  brain ;  thus  a  pointed  body,  such  as  a 
piece  of  stick,  the  end  of  an  umbrella,  or  a  knife  thrust  into  the  orbit, 
may  perforate  its  superior  wall,  producing  a  fatal  wound  of  the  brain. 
The  injury  to  the  brain  through  the  orbital  plate  of  the  frontal  bone 
may  be  fatal  by  the  cerebral  inflammation  that  is  induced  ;  or  the  thrust 
may  extend  deeply,  and,  lacerating  the  internal  carotid  artery,  occasion 
fatal  hemorrhage.  In  one  remarkable  case  recorded  by  N^laton,  a  young 
man  was  wounded  by  the  thrust  of  the  point  of  an  umbrella  in  the 
orbit ;  the  cavernous  sinus  and  internal  carotid  artery  on  the  opposite 
side  were  wounded,  an  arterio-venous  aneurism  formed,  the  eyeball 
became  prominent,  and  death  from  hemorrhage  eventually  resulted  from 
the  giving  way  of  the  aneurism.  Occasionally  inflammation  is  set  up  in 
the  loose  cellulo-adipose  tissue  contained  in  the  orbit,  giving  rise  to 
abscess  which  may  point  in  either  eyelid  ;  or  to  inflammation  extending 
itself  to  the  encephalon.  In  other  cases,  wounds  of  the  orbit  may  be 
followed  by  loss  of  vision,  without  the  eyeball  being  touched  ;  either  in 
consequence  of  injury  of  the  optic  nerve,  or  perhaps  from  the  division 
of  some  of  the  other  nerves  of  the  orbit  producing  sympathetic  amaurosis, 
as  occasionally  happens  even  from  ordinary  wounds  of  the  face  impli¬ 
cating  some  of  the  terminal  branches  of  the  fifth  pair. 

Eye. — Injuries  of  the  eyeball  are  so  commonly  followed  by  impair¬ 
ment  or  total  loss  of  vision  as  to  constitute  a  most  important  series  of 
accidents ;  the  delicacy  of  the  structure  of  this  organ  being  such,  that 
injury  of  it  is  often  followed  by  complete  opacity  and  loss  of  sight.  The 
impairment  of  vision  may  be  the  result  of  direct  violence  applied  to  the 
organ,  injuring  its  more  transparent  parts  or  displacing  the  lens;  or  it 
may  arise  indirectly  from  various  causes  which  will  be  presently  des¬ 
cribed. 

The  injuries  of  the  eye  produced  by  direct  violence^  may  be  divided 
into  contusions  and  wounds. 

Contusion  of  the  Eyeball^  without  rupture  or  apparent  injury  of  any 
of  its  structures,  may  give  rise  to  such  concussion  of  the  retina  as  to  be 
followed  by  temporary  or  permanent  amaurosis.  More  frequently  con¬ 
tusions  of  the  eye  are  accompanied  by  extravasation  of  blood  under  the 
conjunctiva,  and  much  ecchymosis  of  the  eyelids.  A  ‘‘black  eye”  is  best 
treated  by  the  continuous  application  of  a  weak  spirit  lotion. 

Contusion  of  the  Eye  with  Rupture  of  some  of  the  Structures  of  the 
Ball  is  a  most  serious  accident.  The  cornea  may  be  ruptured,  the 
humors  lost,  and  vision  permanently  destroyed.  Most  frequently  the 
rupture  is  internal,  the  outer  tunics  escaping  all  injury.  In  this  case 
w’e  may  have  an  extravasation  of  blood  into  the  eye,  completely  filling 
the  anterior  chamber,  hiding  and  complicating  deeper  mischief  within 
the  ball.  This  condition,  termed  hdemophthalmia^  is  frequently  asso¬ 
ciated  with  separation  of  the  cilliary  margin  of  the  iris.  In  other  cases, 
the  crystalline  lens  may  be  driven  into  the  vitreous  humor,  be  engaged 
in  the  pupillary  aperture,  or  fall  forwards  into  the  anterior  chamber. 
As  a  consequence  of  such  injuries,  the  eye  usually  becomes  inflamed, 
with  intense  frontal  and  circumorbital  pain  ;  disorganization  of  the  ball 
and  ultimate  loss  of  vision  ensuing. 


WOUNDS  OF  THE  EYEBALL. 


511 


The  Treatment  must  always  be  of  an  active  anti-inflammatory  cha-' 
racter.  Blood  should  be  freely  taken  from  the  arm  by  venesection,  and 
from  the  temple  by  cupping,  the  iris  being  dilated  by  the  application  to 
the  eye  of  a  solution  of  the  sulphate  of  atropine,  of  the  strength  of 
two  grains  to  an  ounce  of  distilled  water;  the  patient  must  be  kept  in  a 
darkened  room,  on  a  strictly  anti-inflammatory  regimen,  and  should  be 
put  under  the  influence  of  calomel  and  opium,  as  speedily  as  possible. 
In  this  way  the  inflammation  will  be  subdued,  the  effused  blood  ab¬ 
sorbed,  and  perhaps  vision  restored.  In  some  cases,  however,  opaque 
masses  and  bands  of  lymph  will  be  deposited  in  the  anterior  chamber 
and  the  pupillaiy  aperture,  preventing  more  or  less  completely  the  entry 
of  light.  If  the  lens  be  displaced  into  the  posterior  chamber,  it  must  be 
left  there ;  if  into  the  anterior,  it  may  be  extracted  through  the  cornea. 

Wounds  of  the  Eyeball  may  be  divided  into  those  that  are  merely 
superficial,  and  do  not  penetrate  into  its  chambers ;  and  those  that  per¬ 
forate  its  coats. 

Non-penetrating  Wounds  are  usually  inflicted  by  splinters  of  iron,  or 
other  metallic  bodies,  which  become  fixed  in  the  cornea,  or  between  one 
of  the  eyelids  and  the  ball.  Yery  painful  and  troublesome  injuries  are 
sometimes  inflicted  by  scratches  of  the  eyeball  with  the  nails  of  children. 

In  the  Treatment  of  these  superficial  injuries,  the  first  point  is  neces¬ 
sarily  to  remove  an}^  foreign  body.  If  it  be  fixed  on  the  cornea,  as  com¬ 
monly  happens,  it  may  be  picked  off  with  the  point  of  a  lancet  or 
cataract-needle  ;  if  it  be  a  splinter  of  iron  that  has  been  so  lodged,  it  is 
well  to  bear  in  mind  that  a  small  brown  stain  will  be  left  after  the  me¬ 
tallic  spiculum  has  been  taken  off;  this,  however,  will  disappear  in  the 
course  of  a  few  days.  In  order  to  remove  foreign  bodies  lodged  between 
the  ball  and  the  eyelids,  the  latter  must  be  everted  so  that  the  angle 
between  the  palpebral  and  the  occular  conjunctiva  may  be  properly  ex¬ 
amined.  For  this  purpose  the  lower  eyelid  need  only  be  drawn  down, 
whilst  the  patient  is  directed  to  look  up  ;  but  the  eversion  of  the  upper 
eyelid  requires  some  skill.  It  is  best  efected  by  laying  a  probe  horizon¬ 
tally  across  it,  immediately  above  the  tarsal  cartilage  ;  the  Surgeon  then, 
taking  the  eyelashes  and  cilary  margin  lightly  between  his  finger  and 
thumb,  draws  down  the  eyelid  at  the  same  time  that  he  evert  it  by  press¬ 
ing  the  proble  firmly  backwards  and  downwards  against  the  eyeball ; 
the  patient  should  then  look  down  in  order  that  the  whole  of  the  upper 
part  of  the  conjunctiva,  where  the  foreign  body  will  probably  be  found, 
may  be  carefully  examined. 

Penetrating  Wounds  of  the  eyeball  present  great  variety ;  they  are 
commonly  inflicted  by  bits  of  stick,  steel-pens,  children’s  toys,  and  not 
unfrequently  during  the  shooting  season  by  the  explosion  of  faulty 
percussion-caps,  or  the  lodgement  of  a  stray  shot  in  the  eye.  In  all  cases 
these  accidents  are  highly  dangerous  to  vision ;  and,  when  the  foreign 
bod}^  lodges,  sight  is  usually  permanently  lost.  The  danger  usually 
arises  either  from  the  eye  being  opened  to  such  an  extent  that  the  hu¬ 
mors  escape,  or  else  that,  the  iris  becoming  engaged  in  a  wound  in 
the  cornea,  a  hernial  prolapse  of  it  occurs.  The  remoter  consequences 
usually  arise  from  inflammation  taking  place  within  the  globe,  so  as  to 
produce  an  opaque  cicatrix  of  the  cornea  or  of  the  capsule  of  the  lens  ; 
or  else  adhesions  may  form,  stretching  across  between  the  iris  and  the 
lens,  or  between  these  parts  and  the  posterior  surface  of  the  cornea ;  or 
inflammation  may  take  place  in  all  the  structures  of  the  ball,  giving  rise 
to  rapid  and  deep  disorganization. 

The  Treatment  of  penetrating  wounds  is  strictly  anti-inflammatory. 


512  INJUKIES  OF  THE  FACE  AND  ADJACENT  PARTS. 

Bleeding  in  the  arm,  cupping  on  the  temples,  low  diet,  a  darkened 
room,  and  the  administration  of  calomel  and  opium,  are  the  principal 
points  to  be  attended  to.  If  the  iris  have  protruded  through  a  wound 
in  the  cornea,  it  should  be  carefully  pushed  back,  and  a  drop  or  two  of 
the  solution  of  atropine  put  upon  the  e3'e.  If  it  cannot  be  returned,  it 
may  be  removed  with  a  pair  of  fine  curved  scissors  ;  and,  at  a  later 
period,  any  staphylomatous  tumor  that  may  form  should  be  touched 
repeatedly  with  a  pointed  piece  of  nitrate  of  silver.  If  there  be  a  ten¬ 
dency  to  the  formation  of  adhesions,  or  to  the  deposit  of  lymph  within 
the  pupil  or  the  anterior  chamber,  our  principal  reliance  should  be  upon 
small  doses  of  calomel,  in  conjunction  with  opium.  If  the  lens  or  its 
capsule  have  become  opaque,  traumatic  cataract  thus  forming,  extraction 
may  be  required  at  a  later  period  of  the  case. 

If  the  e3"e  be  so  extensively  opened  or  deeply  injured  that  vision  is 
irreparably  lost,  and  extensive  suppurative  inflammation  in  it  and  in  the 
structures  of  the  orbit  is  threatened,  the  sooner  the  globe  is  extirpated 
the  better;  the  patient  being  thus  saved  much  local  and  constitutional 
disturbance,  and  the  danger  of  s^^mpathetic  affection  of  the  other  eye 
being  diminished. 

Indirect  injury  of  the  eye  often  follows  injuries  of  the  nervous  system. 
Thus  impairment  of  vision  may  be  produced  by  concussion  of  the  eye¬ 
ball  through  blows  on  the  head;  by  injuries  of  the  face  implicating  the 
fifth  pair  of  nerves;  by  injury  of  the  spine;  or  by  injury  of  the  sympa¬ 
thetic. 

Concussion  of  the  Eye  may  be  produced  by  a  direct  blow  on  the 
organ ;  or  it  may  be  the  result  of  a  blow  on  some  other  part  of  the  head 
or  face.  In  the  latter  case,  the  injury  is  dependent  on  the  transmission 
of  the  force  through  the  bones  of  the  head  or  face  to  the  structures 
within  the  orbit.  The  resulting  impairment  of  vision  is  at  its  worst  at 
the  moment  of  the  injury,  and  either  slowl}^  disappears,  or  becomes 
permanent  in  consequence  of  the  development  of  structural  changes  in 
the  eye. 

That  indirect  violence  may  produce  serious  lesion  of  the  ej^e,  is 
evident  from  the  fact  that  the  lens  has  been  in  this  way  dislocated  with¬ 
out  any  direct  injury  having  been  inflicted  on  the  eye  itself.  Deyber 
relates  a  case  in  which  cataract  was  induced  by  a  wound  of  the  eyebrow 
from  a  stone,  the  e3'e  itself  being  otherwise  uninjured:  and  I  have  seen 
cataract  occur  in  an  otherwise  healthy  woman  aged  40,  three  or  four 
months  after  the  receipt  of  a  blow  on  the  malar  bone  in  a  railway  colli¬ 
sion.  It  also  often  happens  that,  in  cases  of  a  general  sliock  to  the 
system,  obscuration  and  impairment  of  vision  gradually  manifest  them¬ 
selves. 

When  impairment  of  vision  remains  permanent,  or  is  graduall3^  devel¬ 
oped,  after  concussion,  it  is  due  to  interference  with  the  nutrition  of  the 
structures  of  the  eye.  In  such  cases,  atrophy  of  the  retina  may  be 
discovered  by  ophthalmoscopic  examination.  iTie  development  of  cata¬ 
ract  after  blows  on  the  eyebrow  or  cheek  is  to  be  accounted  for  by  the 
frontal  or  infraorbital  branches  of  the  fifth  nerve  being  implicated  and 
irritated,  so  as  to  impair  the  nutrition  of  the  globe. 

The  eye  may  also  suffer  in  consequence  of  Wound  or  Irritation  of  the 
Branches  of  the  Fifth  Pair  of  Nerves.  This  has  long  been  observed. 
Hippocrates  speaks  of  loss  of  vision  consequent  on  wounds  of  the  eye^ 
brow ;  and  makes  the  very  accurate  observation,  that  the  impairment  is 
less  when  the  wound  is  recent,  but  increases  as  cicatrization  advances. 
Fabricius  Hildanus  and  La  Motte  relate  cases  in  which  blindness 


IMPAIEMENT  OF  VISION  FROM  SPINAL  INJURY.  513 


followed  wounds  of  the  outer  angle  of  the  orbit.  Morgagni  relates  the 
case  of  a  lady  who,  in  consequence  of  the  overturning  of  a  carriage,  was 
wounded  by  some  splinters  of  glass  in  the  upper  eyelid.  The  eyeball 
was  uninjured:  but  vision  became  graduall}^  impaired,  and  was  almost 
lost  by  the  fortieth  day  after  the  accident. 

It  is  by  no  means  necessary  for  the  production  of  impaired  vision 
after  injury  of  parts  of  the  fifth  nerve,  that  there  should  be  an  actual 
wound  :  a  simple  contusion  is  sufiicient.  Wardrop  states  that  it  is  only 
where  the  frontal  nerve  is  wounded  or  injured  and  not  divided,  that 
amaurosis  takes  place.  Indeed,  in  some  cases,  amaurosis  has  been 
cured  by  division  of  the  nerve  after  its  partial  injury.  That  it  is  the 
irritation,  and  not  complete  division  of  the  nerve,  that  leads  to  loss  of 
vision,  is  in  accordance  with  the  view  of  Brown-Sequard,  that  the  imme¬ 
diate  effects  of  section  of  a  nerve  are  very  different  from  those  which 
are  observed  as  the  result  of  its  irritation. 

The  loss  of  vision  may  come  on  instantaneously,  as  in  a  case  related 
by  Wardrop  of  a  sailor  struck  b}^  a  ramrod  on  the  eyebrow;  after  a  few 
da3’s,  as  in  a  case  recorded  by  Chelius  where  the  loss  of  vision  came  on 
eight  daj^s  after  a  blow  in  the  ej^ebrow ;  or  after  a  longer  lapse  of  time, 
as  in  most  of  the  recorded  cases.  In  the  great  majority  of  cases  the 
impairment  of  vision  is  at  first  slight,  and  gradually  goes  on  to  com¬ 
plete  loss  of  sight. 

In  what  way  can  irritation  of  a  branch  of  the  trifacial  nerve,  unac¬ 
companied  b^’  an3"  direct  injury  of  the  eyeball  or  the  structures  of 
the  orbit,  produce  instantaneously  or  remotely  loss  of  vision  ?  Some 
observers  have  attributed  this  to  the  propagation  of  irritation  along 
the  sheath  of  the  nerve  to  the  trunk  of  the  ophthalmic  division,  and 
thence  along  to  the  sheath  of  the  optic  and  the  retina.  But  there  is  no 
evidence  of  such  a  propagation  ;  and  this  explanation  would  not  account 
for  those  cases  in  which  blindness  suddenly  supervened.  That  injury 
of  the  fifth  nerve  produces  important  changes  in  the  ej’e,  has  been 
incontestabW  determined  in  late  3rears  by  the  experiments  of  Snellin, 
Schiff,  Biittner,  Messner,  and  others;  and  whether  we  explain  the  mor¬ 
bid  changes  that  occur  in  the  e}^  as  a  consequence  of  the  injury  of  the 
nerve  by  the  supposition  that  “  neuro-paralytic”  inflammation  is  set  up 
in  the  globe,  or  suppose  that  the  surface  bj'  losing  its  sensibilitj^  be¬ 
comes  more  liable  to  the  action  of  external  irritants,  matters  little  to 
the  practical  Surgeon. 

Wardrop  sa^’s  that  “the  distribution  of  the  first  branch  of  the  fifth 
pair  or  ophthalmic  branch  explains  how  wounds  of  the  frontal,  infra¬ 
orbital,  and  other  branches  of  nerves  which  form  anastomoses  with  the 
ophthalmic  ganglion,  are  sometimes  followed  b^"  amaurosis.”  Xo  doubt 
it  is  to  the  intimate  connections  that  exist  between  the,  frontal  nerve,  the 
ophthalmic  division  of  the  fifth,  and  the  sj^mpathetic  and  ciliaiy  nerves, 
that  we  must  refer  these  various  morbid  phenomena  resulting  from  its 
irritation.  In  what  vray  this  irritation  of  the  frontal  nerve  exercises  an 
injurious  influence  is  doubtful,  but  the  fact,  as  the  result  of  clinical 
observation,  remains  certain,  that  in  some  cases  it  is  the  primary  and 
determining  cause  of  loss  of  vision. 

Impairment  of  Vision  from  Spinal  Injury — One  of  the  most  frequent 
and  most  troublesome  effects  of  spinal  injury  is  a  certain  degree  of 
impairment  of  vision,  which  assumes  different  characters,  and  comes  on 
at  very  varying  periods  after  the  injury.  There  is  often  a  considerable 
interval  intervenes  between  the  occurrence  of  the  injuiy  and  the  develop¬ 
ment  of  the  e3^e-symptoms ;  and,  if  the  patient  be  confined  to  bed,  and 
VOL.  I. — 33 


514  INJURIES  OF  THE  FACE  AND  ADJACENT  PARTS. 


be  not  called  upon  to  use  his  e3"es,  it  may  be  long  before  he  discovers 
that  their  sight  is  enfeebled.  This  is  more  especiall.y  apt  to  be  the  case, 
as  the  attention  of  the  Surgeon  ma}’  not  be  directed  to  the  state  of  the 
eyes  in  the  first  instance.  The  first  and  most  frequent  s3'mptom  that 
is  complained  of  is  a  dimness  or  weakness  of  the  sight,  so  that  the  patient 
cannot  define  the  outlines  of  small  objects,  and  cannot  see  in  an  obscure 
light.  If  he  attempt  to  read,  he  can  define  the  letters  often  even  of  the 
smallest  print  for  a  few  seconds  or  minutes,  but  the3’  soon  run  into  one 
another,  become  obscure  and  blurred,  and  ill-defined.  Glasses  do  not 
materiall3’,  if  at  all,  improve  this  condition.  There  is  often  in  the  earh’’ 
stages  some  slight  irregularity  in  the  axis  of  the  e3’es,  scarcely  amounting, 
however,  to  a  squint.  This  blurring,  or  indistinctness  of  vision,  is  often 
more  marked  with  respect  to  near  than  to  distant  objects.  After  a  time 
the  patient  usuall3^  suffers  from  irritabilit3"  of  the  e3^es,  and  cannot  bear 
a  strong  light,  even  that  of  an  ordinaiy  window,  in  the  da3’time,  or  un¬ 
shaded  gas  or  lamp-light.  In  consequence  of  this  irritabilit3"  of  the  e3’es, 
the  brows  become  involuntarily  contracted,  and  the  patient  acquires  a 
peculiar  frown  so  as  to  exclude  light  as  much  as  possible.  This  intole¬ 
rance  of  light  ma3"  amount  to  perfect  photophobia,  and  is  then  associated 
with  congestion  of  the  conjunctiva  and  accompanied  b3^  lachr3^mation. 

One  or  both  e3"es  may  be  thus  affected.  Sometimes  one  eye  only  is 
intolerant  of  light.  This  intolerance  of  light  is  usuall3"  accompanied  by 
muscse  volitantes  and  spectra,  rings,  stars,  spots,  flashes,  and  sparks,  or 
an  appearance  of  white-colored  flame.  The  appearance  of  a  fixed  lumi¬ 
nous  spectrum,  a  line,  circle,  or  colored  bar  across  the  field  of  vision,  is 
sometimes  complained  of.  There  is  an  undue  retention  of  the  image  in 
many'  cases ;  and  where  the  patient  has  looked  at  any  fixed  object,  such 
as  the  sun  or  the  fire,  complementary’  spectral  colors,  often  of  the  most 
beautiful  character,  of  vary’ing  degrees  of  intensity’,  will  develop  them¬ 
selves  in  succession.  The  patient  becomes  in  some  cases  conscious  of 
the  circulation  in  his  own  ey’e,  which  becomes  distinctly  visible  to  him, 
even  in  its  pulsatory  character. 

From  this  description  of  the  symptoms  of  the  impairment  of  vision 
that  follows  spinal  injury,  it  would  appear  that  it  is  of  three  distinct 
kinds,  which  may,  however,  be  associated.  1.  Asthenopia,  or  simple 
weakness  of  sight,  such  as  we  meet  with  in  white  atrophy  of  the  retina; 
2.  Irritability’  of  the  eye  and  photopsia  depending  on  hyperaemia  of  the 
retina,  or  on  neuritis  of  it  and  the  optic  nerve ;  and  3.  Loss  of  the 
adjusting  power  of  the  ey’es,  as  happens  in  all  the  sympathetic  nervous 
aflections  of  the  organ.  In  the  ordinary  erethitic  amblyopia  or  amau¬ 
rosis,  these  symptoms  are  not  constant.  They’  vary  in  intensity  at 
different  periods  of  the  day,  being  usually’  worst  in  the  morning.  They 
vary’  with  the  state  of  health,  and  with  the  condition  of  the  mind,  being 
less  marked  as  the  patient  becomes  stronger  and  in  better  spirits,  and 
are  influenced  by  the  weather  and  surrounding  circumstances,  all  those 
of  a  depressing  character  having  a  tendency’  to  aggravate  the  sy’mptoms. 

The  objective  phenomena  presented  by’  the  ey’e,  and  the  ophthalmo¬ 
scopic  appearances  seen  in  the  interior  of  the  globe  in  these  cases,  have 
been  carefully  studied  by  Wharton  Jones  and  Allbutt.  Jones,  in  his  able 
work  “On  Failure  of  Sight  after  Railway  and  other  Injuries,”  states 
that  the  ey’elids  are  usually’ half  closed;  the  eyes  sunken  and  watery ; 
the  veins  of  the  eyeball  congested.  The  movements  of  the  pupils  are 
sometimes  normal ;  at  others  more  sluggish ;  sometimes  more  active  than 
usual.  This  will  necessarily  depend  upon  whether  the  ey’e  be  affected  by 


IMPAIRMENT  OF  VISION  FROM  SPINAL  INJURY.  515 


simple  asthenopia,  or  whether  there  be  some  hypersemic  or  inflammatory 
state  developed  in  its  interior. 

The  ophthalmoscopic  appearances  vary  greatly.  In  some  cases,  as 
Wharton  Jones  observes,  the  morbid  state  on  which  the  failure  of  sight 
and  other  subjective  symptoms  depend,  may  be  at  flrst  confined  to  some 
central  portion  of  the  optic  nervous  apparatus,  and  no  ophthalmoscopic 
evidence  of  implication  of  the  retina  or  optic  disk  may  present  itself  till 
a  more  advanced  stage  of  the  case.  Sooner  or  later,  however,  whether 
as  the  result  of  primary  changes  in  the  fundus,  or  more  slowly  from  the 
effect  of  a  slowl^^  progressive  inflammatory  affection  propagated  from 
the  intracranial  portion  of  the  nervous  apparatus  towards  its  periphery, 
and  thus  inducing  morbid  changes  in  the  optic  nerve  and  its  disk,  we 
find  that  the  ophthalmoscope  reveals  changes  in  the  fundus  of  the  eye. 
“  The  disk,”  says  Wharton  Jones,  “is  seen  to  be  whitish  and  somewhat 
congested ;  the  retinal  veins  are  large,  though  the  fundus  usually  pre¬ 
sents  an  anaemic  aspect,  with  perhaps  some  pigmentous  degeneration  of 
the  retina  round  the  disk.” 

One  or  other  of  these  conditions  occurs  in  the  majority  of  cases  of 
spinal  injury.  Allbutt  says,  “It  is  tolerably  certain  that  disturbance  of 
the  optic  disk  and  its  neighborhood  is  seen  to  follow  disturbance  of  the 
spine,  with  sufficient  frequency  and  uniformity  to  establish  the  proba¬ 
bility  of  a  casual  relation  between  the  two  events.”  He  goes  on  to  say 
that  in  13  cases  of  chronic  spinal  disease  following  accident,  he  found  8 
cases  of  sympathetic  disorder  of  the  eye.  My  experience  fully  accords 
with  that  of  Allbutt.  I  find  that  of  60  cases  of  obscure  spinal  injury, 
without  fracture  or  dislocation,  that  I  have  consecutively  examined, 
there  was  impairment  of  vision  in  42  instances. 

Allbutt  makes  the  interesting  remark,  which  will  be  supported  by  the 
experience  of  all  Surgeons,  that,  in  the  severer  forms  of  spinal  injury, 
those  that  prove  fatal  in  a  few  weeks,  evidences  of  eye-disease  are  not 
met  with.  Of  17  such  cases  he  found  no  evidence  of  eye-disease  in  any 
one  instance.  This  observation  aflferds  a  most  complete  answer  to  an 
objection  that  has  often  been  urged,  that  as  sj^mpathetic  affection  of  the 
eye  is  rarely  met  with  in  severe  injuries  of  the  spine,  such  as  fracture  and 
displacement  of  the  vertebrae  with  traumatic  lesion  of  the  cord,  its 
occurrence  in  the  less  immediately  severe  and  more  obscure  forms  of 
injury  can  scarcely  be  looked  upon  as  the  direct  result  of  the  spinal 
mischief.  It  would  appear,  however,  from  the  observations  of  Allbutt, 
which  I  can  entirely  confirm,  that  it  is  in  these  very  cases  that  it  is  met 
with. 

That  a  certain  portion  of  the  spinal  cord  exercises  a  direct  influence 
on  the  eyes,  has  been  incontestably  established  by  the  experiments  of 
modern  physiologists.  Budge  and  Waller,  in  1851,  demonstrated  that 
the  filaments  of  the  sympathetic  that  supply  the  eye  take  their  origin 
from  that  part  of  the  spinal  cord  which  is  contiguous  to  the  origin 
of  the  first  pair  of  dorsal  nerves;  and  that  the  portion  of  the  spinal 
axis  which  extends  from  the  fifth  cervical  to  the  sixth  dorsal  vertebra, 
and,  according  to  Brown-Sequard,  as  far  as  the  twelfth  dorsal,  possesses 
a  distinct  influence  on  the  organs  of  vision.  Hence  by  these  physiolo¬ 
gists  it  has  been  termed  the  “  cilio-spinal,”  and  by  Claude  Bernard  the 
“  oculo-spinal”  axis.  It  has  been  determined  as  the  result  of  numerous 
experiments,  that  the  partial  division  of  this  cilio-spinal  axis  exercises 
various  disturbing  influences  on  the  size  of  the  pupils,  on  the  vascu¬ 
larization  of  the  conjunctiva,  and  probably  of  the  deeper  ocular  tissues, 
and  on  the  state  of  the  bloodvessels  of  the  ear,  exactly  similar  to  those 


516  INJURIES  OF  THE  FACE  AND  ADJACENT  PARTS. 


that  are  occasioned  by  the  section  of  the  cervical  sympathetic.  The 
conclusion  that  must  necessarily  be  deduced  from  these  observations  is, 
that  this  portion  of  the  spinal  cord — the  oculospinal  axis — includes 
within  itself  both  vaso-motor  and  oculo-pupillary  filaments  which  are 
connected  with  the  cervical  portion  of  the  sympathetic. 

Claude  Bernard  has  pointed  out  clearly  the  fact  that  the  vaso-motor 
and  oculo-pupillary  nerves  possess  different  refiex  actions.  By  dividing 
the  first  two  dorso-spinal  roots,  he  finds  that  the  oculo-pupillar  phe¬ 
nomena  are  produced  without  occasioning  the  vaso-motor  effects  of  vas¬ 
cular  injection  and  increase  of  temperature  ;  whereas,  by  dividing  the 
ascending  sympathetic  filament  between  the  second  and  third  ribs,  the 
vaso-motic  phenomena  are  developed  in  the  head  without  any  infiuence 
being  excited  on  the  eye  through  the  medium  of  oculo-pupillary  filaments. 
He  sums  up  his  observations  as  follows.  “  The  vaso-motor  and  the 
oculo-pupillary  nerves  do  not  act  in  the  same  way.  Thus  a  slight  irri¬ 
tation  of  the  auricular  nerve  only  occasions  vascularization  of  the  cor¬ 
responding  side  ;  whilst  the  same  irritation  produces  refiex  movements 
in  both  eyes  at  the  same  time.  The  refiex  vascular  actions  do  not  appear 
to  be  capable  of  being  produced  on  the  opposite  side  to  that  which  is 
irritated  (d’une  maniere  croisee)  ;  and,  besides  this,  they  are  limited  and 
do  not  extend  beyond  a  certain  determined  line  of  circumscription.  All 
this  is  in  striking  contrast  with  the  oculo-pupillar  actions,  which  are  on 
the  contrary  general  and  crossed.” 

Clinical  observations  support  the  result  of  physiological  experiment 
as  to  the  connection  that  subsists  between  the  oculo-spinal  axis  of  the 
cord  and  the  integrity  of  vision;  The  records  of  surgery  contain  numerous 
illustrations  of  the  injurious  infiuence  on  the  sight  of  blows  infiicted  on 
the  lower  cervical  and  upper  dorsal  spine.  Allbutt,  however,  remarks, 
that  those  injuries  and  concussions  of  the  spine  that  occur  high  up  are 
more  injurious  to  vision  than  such  as  are  infiicted  on  the  lower  portion 
of  the  vertebral  column. 

To  what  is  this  impairment  of  vision  due  ?  Allbutt,  who  has  studied 
the  subject  with  much  care,  gives  his  opinion,  in  which  I  fully  coincide, 
so  clearly,  that  I  cannot  do  better  than  to  quote  his  own  words.  “  In 
default  of  a  series  of  autopsies,  we  seem  to  be  led  towards  the  conjec¬ 
ture  that  hypersemia  of  the  back  of  the  eye,  following  injury  to  the  spine, 
is  probably  dependent  upon  a  greater  or  less  extension  of  the  meningeal 
irritation  up  to  the  base  of  the  brain.  Now,  have  we  any  reason  to  sup¬ 
pose  that  spinal  meningitis  does  creep  up  into  the  encephalon  ?  We 
have :  for,  setting  aside  the  curious  head-symptoms  such  patients  often 
present,  here  the  actual  demonstration  of  autopsy  comes  to  aid  us.  It 
is  tolerably  well  known  to  careful  pathologists  that  encephalic  menin¬ 
gitis  is  a  very  common  accompaniment  of  spinal  meningitis.  It  is  scarcely 
needful  to  point  out  if  this  explanation  of  an  ascending  meningitis  be  the 
correct  one,  it  accords  with  my  observation,  stated  above,  that,  in  general, 
the  higher  the  injury  to  the  spine  the  sooner  the  affection  of  the  eye.” 

Mouth. — Wounds  of  the  mouth  are  seldom  met  with,  except  as  the 
result  of  gunshot  violence.  The  amount  of  injury  done  to  the  soft  struc¬ 
tures,  however  great,  is  usually  only  secondary  to  the  mischief  that 
results  to  the  brain,  spinal  cord,  jaws,  and  skull,  and  must  of  course  be 
treated  on  the  ordinary  principles  of  treatment  of  gunshot  and  lacerated 
wounds. 

Tongue. — Wounds  of  the  tongue  usually  occur  from  its  tip  or  sides 
being  caught  between  the  teeth  during  an  epileptic  fit.  They  have  been 
known  to  be  inflicted  by  insane  patients,  in  attempts  to  excise  or  bite  off* 


WOUNDS  OF  THE  THROAT. 


517 


this  organ.  Should  the  hemorrhage  he  free,  the  application  of  a  ligature, 
or  even  of  the  actual  cautery,  may  be  needed.  These  wounds  generally 
assume  a  sloughy  appearance  for  a  few  days  ;  then  they  clean  up,  and 
granulate  healthily.  It  is  useless  to  bring  the  edges  together  by  sutures, 
which  readily  cut  out.  If,  however,  a  large  portion  of  the  tip  be  nearl}^ 
detached,  it  must  be  supported  in  this  way  ;  but  the  threads  should  be 
thick  and  passed  deeply.  Pieces  of  tobacco-pipe  are  occasionally  driven 
into  and  broken  off  in  the  substance  of  the  tongue,  and  they  either  give 
rise  to  very  free  hemorrhage,  or  the  wound  may  close  and  heal  over  the 
foreign  body,  the  existence  of  which  may  not  be  known  to  the  patient. 
In  a  case  of  this  kind,  where  a  man  complained  of  much  pain  and  stiff¬ 
ness  in  the  tongue,  with  difficulty  in  deglutition,  I  found,  on  examina¬ 
tion,  a  hard  swelling  towards  the  base  of  the  organ;  and  on  cutting 
down  upon  this  extracted  three  inches  of  the  stem  of  a  tobacco-pipe, 
which  had  been  lodged  there  for  several  months. 

The  Palate  and  the  Pharynx  are  sometimes  lacerated  by  gunshot 
injuries  of  the  mouth;  or  the  w’ound  may  result  from  something  that  the 
patient  happens  to  have  between  his  lips  being  driven  forcibly  backwards 
into  his  mouth.  Thus,  a  tobacco-pipe  may,  by  a  blow  on  the  face,  be 
driven  deeply  into  the  substance  of  the  tongue,  or  perhaps  into  the 
phaiynx,  wounding  and  lodging  behind  the  arches  of  the  palate,  breaking 
off  short;  the  fragment  that  is  left  in  giving  rise  to  abscess,  to  ulceration 
of  the  vessels,  and  perhaps  to  fatal  secondarj’'  hemorrhage.  In  a  case 
that  was  under  my  care  some  time  ago,  the  soft  palate  was  nearly  de¬ 
tached  from  the  palatial  bones  b}-  a  deep  transverse  wound,  caused  by 
the  end  of  a  spoon  being  forcibly  driven  into  the  mouth ;  good  union 
took  place  eventually,  the  part  having  been  stitched  together  by  a  few 
points  of  suture. 


CHAPTER  XXYII. 

INJURIES  OF  THE  THROAT:  AND  ASPHYXIA. 

INJURIES  OF  THE  LARYNX  AND  TRACHEA. 

Dislocation  and  Fracture  of  the  Larynx. — The  cartilages  of  the 
larynx  may  be  displaced, dislocated  as  it  were,  by  violent  blows:  or  they 
may  be  fractured  by  a  squeeze,  the  rupture  in  some  cases  taking  place 
transverseljq  in  others  longitudinally.  Digital  examination  will  at  once 
detect  the  nature  of  the  injury.  In  all  these  injuries  there  is  danger  of 
asph3’xia,  which  indeed  may  be  induced  by  simple  concussion  of  the 
laiynx.  Should  these  symptoms  be  very  urgent,  tracheotomy  may  be 
required ;  if  not,  attention  to  position  and  support  of  the  head  will  suffice. 

Wounds  of  the  Throat. — These  are  of  great  frequency  and  impor¬ 
tance,  implicating,  as  they  do,  some  of  the  most  important  organs  in  the 
body.  They  ma^’’  be  divided  into  three  categories: — 

1.  Those  that  do  not  extend  into  the  Air  or  Food-passages. 

2.  Those  that  implicate  the  Air-passage,  with  or  without  injury  of  the 
(Esophagus. 

3.  Those  that  are  accompanied  b^"  injury  of  the  Spinal  Cord. 

All  these  injuries  are  most  commonly  suicidal,  and  may  be  inflicted 
with  every  variety  of  cutting  instrument ;  except  where  the  spinal  cord 


518 


INJUEIES  OF  THE  THROAT. 


is  injured,  which  must,  in  cases  of  suicide,  be  the  result  of  gunshot 
wound,  and  is  necessarily  fatal.  Though  incised,  they  are  often  jagged, 
and  partake  somewhat  of  the  character  of  lacerated  wounds,  with  great 
gaping  of  the  edges. 

1.  Wounds  not  extending  into  the  Air  or  Food-passages. — In  these 
wounds,  there  is  very  commonly  free  and  even  fatal  hemorrhage,  and  this 
sometimes  though  none  of  the  larger  arterial  or  venous  trunks  have  been 
divided ;  the  blood  flowing  abundantly  from  the  venous  plexuses  and 
from  the  thyroid  body.  If  the  larger  arteries  be  touched,  as  the  carotid 
and  its  primaiw  branches,  the  hemorrhage  may  be  so  abundant  as  to 
give  rise  to  almost  instantaneous  death.  Another  source  of  danger  in 
these  cases  proceeds  from  the  admission  of  air  into  the  veins  of  the  so- 
called  “  dangerous  region’’  of  the  neck.  For  this  a  free  wound  is  by  no 
means  necessarj’’,  as  is  instanced  hy  a  remarkable  case  that  occurred  some 
years  ago  near  London,  in  which  the  introduction  of  a  seton  into  the  fore¬ 
part  of  the  neck  was  followed  by  death  from  this  cause. 

Wounds  of  the  internal  jugular  vein  are  necessarily  very  dangerous. 
There  is  not  only  the  ordinary  risk  of  primary  hemorrhage  from  a  vessel 
of  such  large  size  and  directly  communicating  with  the  cerebral  sinuses, 
but  the  special  danger  of  the  introduction  of  air  into  it ;  should  these 
accidents  be  safely  got  over,  the  secondaiy  ones  of  recurrent  hemorrhage 
and  pysemia  may  j^et  have  to  be  met.  The  ligature  of  the  vessel  above 
and  below  the  wound  in  it,  exactly  as  if  it  were  an  artery  that  had  been 
opened,  is  the  only  course  that  can  be  safely  pursued.  In  one  case  in 
which  this  was  being  done,  I  saw  and  heard  air  enter  the  vein  as  it  was 
being  raised  for  the  passage  of  the  ligature,  but  the  patient  made  a  quick 
recovery. 

The  large  nerves,  such  as  the  vagus  and  phrenic,  can  scarcely,  in  a 
suicidal  wound,  be  divided  without  injury  to  the  neighboring  vessels. 
The  division,  however,  of  the  respiratory  nerves  on  one  side  only,  or 
even  of  one  of  them,  would  in  all  probability  be  fatal  in  man,  by  inter¬ 
fering  with  the  proper  performance  of  the  respiratory  act.  In  a  case 
with  which  I  am  acquainted,  where  the  phrenic  nerve  was  divided  during 
ligature  of  the  subclavian  artery,  death  resulted  in  a  few  days  from  con¬ 
gestion  of  the  lungs. 

In  the  Treatment  of  wounds  of  the  neck  of  this  category,  the  principal 
points  to  be  attended  to  are,  in  the  first  place,  the  arrest  of  hemorrhage 
by  the  ligature  of  all  bleeding  vessels,  whether  arterial  or  venous ;  and 
secondly,  bringing  together  the  lips  of  the  wound.  If  the  cut  be  longi¬ 
tudinal,  this  may  be  done  by  strips  of  plaster:  if  transverse,  by  a  few 
points  of  suture  and  by  position,  the  head  being  fixed,  with  the  chin 
almost  touching  the  sternum,  and  retained  in  this  posture  by  tapes 
passing  from  the  nightcap  to  a  piece  of  bandage  fixed  round  the  chest. 
I  have  had  under  my  care  one  case  in  which,  owing  to  the  projection 
and  mobility  of  the  larynx,  the  wound  did  not  unite,  a  large  and  deep 
gap  being  left,  which  required  a  series  of  plastic  operations  in  order  to 
efiect  its  closure. 

2.  Wounds  implicating  the  Air-passage. — The  air-passage  is  commonly 
wounded  in  suicidal  attempts.  It  may  be  known  to  be  opened  by  the  air 
being  heard  and  seen  to  bubble  in  and  out  of  the  wound  during  respira¬ 
tion.  These  wounds  varj^  much  in  extent,  from  a  small  puncture  with 
the  point  of  a  penknife  to  a  cut  extending  completely  across  the  throat, 
and  even  notching  the  vertebrae.  They  are  frequently  complicated  with 
injuries  of  the  larger  vessels  and  nerves,  and  sometimes  with  wound  of 
the  oesophagus.  Most  commonly  the  cut  is  made  high  up  in  the  neck  ; 


WOUNDS  OF  THE  AIR-PASSAGE. 


519 


for  the  suicide,  thinking  that  it  is  the  opening  into  the  air-passage  that 
destroys  life,  draws  the  razor  across  that  part  of  the  throat  where  this  is 
most  prominent  and  easily  reached ;  and  thus,  by  not  wounding  the  larger 
vessels,  which  are  saved  by  the  projection  of  the  larynx,  frequently  fails 
in  accomplishing  his  object. 

These  wounds  occur  in  four  situations:  above  the  Hyoid  Bone;  in 
the  Th3’'ro-hyoid  Space;  through  the  Larynx  ;  and  through  the  Trachea. 

The  wound  may  be  made  above  the  Hyoid  Bone ;  the  cut  extending 
into  the  mouth  and  wounding  the  root  of  the  tongue.  A  wound  in  this 
situation  is  usuallj^  attended  with  much  hemorrhage ;  and  there  is  great 
trouble  in  feeding  the  patient,  as  the  power  of  swallowing  is  completel}’’ 
lost. 

The  wound  may  be  inflicted  in  the  Thyro-hyoid  Space,  laying  tlie 
phar^mx  open,  but  being  altogether  above  the  larynx.  This  is  the  most 
common  situation  for  suicidal  attempts.  In  man^’  cases,  the  incision  is 
carried  so  low  as  to  shave  off  or  parti}’'  to  detach  the  epiglottis  and  the 
folds  of  mucous  membrane  around  it.  In  other  cases,  the  edges  of  the 
glottis  or  the  arytsenoid  cartilages  are  injured,  the  cut  extending  back 
to  the  bodies  of  the  vertebrae.  Here  also  there  is  great  difficulty  in 
swallowing  and  great  risk  of  the  sudden  supervention  of  oedema  of  the 
glottis,  and  consequent  suffocation. 

When  the  Larynx  is  wounded  the  incision  is  usually  transverse  ;  but 
I  have  seen  a  longitudinal  cut  made  through  the  larynx,  so  as  to  split 
the  thyroid  and  cricoid  cartilages  perpendicularly.  In  these  cases  of 
wounded  larynx,  there  is  much  danger  of  the  blood  from  the  superficial 
parts  trickling  into  the  air-passage  and  asphyxiating  the  patient,  and  of 
inflammation  of  the  bronchi  and  lungs  supervening  at  a  later  period. 

Wounds  of  the  Trachea  are  not  so  common  as  those  of  the  larynx, 
from  which  they  differ  but  little  in  the  attendant  dangers. 

The  (Esophagus  is  seldom  wounded,  as  it  can  only  be  reached  through 
the  trachea  by  a  deep  cut,  which  will  probably  implicate  the  large  vessels. 

Effects. — There  are  various  sources  of  danger  in  wounds  of  the  neck 
implicating  the  air-passage.  The  hemorrhage,  w’hether  it  proceed  from 
any  of  the  larger  trunks,  or  consist  of  general  oozing  from  a  vascular 
surface,  may  either  prove  directly  fatal  by  the  amount  of  blood  lost,  or 
indirectly  in  consequence  of  the  blood  trickling  into  the  air-tube,  and, 
by  accumulating  in  its  smaller  divisions,  producing  suffocation. 

Asphyxia  may  supervene,  either  in  the  way  already  mentioned,  or, 
when  the  wound  has  been  inflicted  above  the  larynx,  from  the  occurrence 
of  oedema  of  the  glottis.  It  may  likewise  occur  when  the  external  open¬ 
ing  is  very  small,  and  occasionally  happens  suddenly  when  the  wound 
is  nearly  closed. 

Another  source  of  danger  is  the  loss  of  the  natural  sensibility  of  the 
glottis,  in  consequence  of  which  it  no  longer  contracts  on  the  application 
of  a  stimulus.  Hence  food  taken  in  by  the  mouth  may  pass  into  the 
larnynx  and  appear  at  the  external  wound,  even  though  neither  the 
pharynx  nor  the  oesophagus  has  been  wounded.  This  I  have  observed 
in  many  cases  of  cut  throat ;  hence  the  presence  of  food  in  the  wound 
cannot  in  all  cases  be  considered  an  evidence  of  injury  to  the  food-pas¬ 
sage.  This  occurrence  is  always  a  bad  sign,  and  is  never  met  with  until 
a  semi-asphyxial  condition  has  come  on,  by  which  the  nervous  sensi¬ 
bilities  are  blunted,  or  until  inflammation  has  been  set  up  about  the  rima 
glottidis,  giving  rise  to  so  much  sw'ellingas  to  interfere  with  the  natural 
actions,  and  to  deaden  the  perception  of  the  part  to  the  contact  of  a 
foreign  body.  In  these  cases  also  the  sensibility  of  the  air-passage 


520 


INJURIES  OF  THE  THROAT. 


generall}^  is  much  lowered,  so  that  mucus  accumulates  in  the  bronchi, 
even  to  a  dangerous  extent,  the  patient  not  feeling  the  necessit}"  for 
expectoration,  and  often,  indeed,  having  much  difficulty  in  emptjdng 
his  chest. 

The  occurrence  of  bronchitis  and  pneumonia^  either  from  the  inflam¬ 
mation  extending  downwards  from  the  wound,  or  in  consequence  of  the 
cold  air  entering  the  lungs  directly,  without  being  warmed  b}’’  passing 
through  the  nasal  cavities,  is  perhaps  the  most  serious  complication  that 
can  happen,  and  is  a  frequent  cause  of  death  in  patients  who  survive 
the  immediate  effects  of  the  wound. 

The  depressed  mental  condition  of  the  patient  also  is  usually  unfa¬ 
vorable  to  recovery  in  all  those  instances  in  which  the  wound  is  suicidal, 
disposing  him  to  the  occurrence  of  low  forms  of  inflammatory  mischief. 

Treatment. — The  same  general  principles  are  required  as  in  the  man¬ 
agement  of  those  wounds  of  the  throat  that  do  not  interest  the  mucous 
canals  in  this  region.  Hemorrhage  must  be  arrested  by  ligature  of  all 
the  bleeding  vessels,  whether  arteries  or  veins,  so  that  no  oozing  or 
trickling  into  the  wound  ma}^  take  place.  In  some  cases  the  hemorrhage 
consists  principally  of  general  venous  oozing  which  cannot  be  stopped 
by  ligature,  the  patient  drawing  a  large  quantit}^  of  blood  into  the  air- 
passage  through  the  wound.  In  these  circumstances  I  have  found  it 
useful  to  introduce  a  large  silver  tube  into  the  aperture  in  the  windpipe, 
and  to  plug  the  wound  around  it.  So  soon  as  the  bleeding  has  fairly 
ceased,  the  plugs  and  the  tube  must  be  removed. 

The  edges  must  next  be  brought  together  by  a  few  stitches  introduced 
at  the  sides,  and  by  attention  to  position,  the  head  being  fixed  by  tapes 
as  described  at  p.  518.  I  think,  with  Liston,  that  in  these  cases  the 
Tvound  should  never  be  closely  sewed  up,  nor  stitches  introduced  into 
the  centre  of  the  cut.  If  the  centre  of  the  integuments  be  closely  drawn 
together,  coagula  may  accumulate  behind  them,  in  the  deeper  parts  of 
the  wound,  so  as  to  occasion  a  risk  of  suffocation  ;  and,  as  the  wound 
must  eventually  close  by  granulation,  no  material  advantage  can  pos¬ 
sibly  be  gained  by  this  practice.  There  is  an  exception,  however,  to  this 
rule  of  not  using  stitches  in  the  central  part  of  the  wound  in  cut  throat. 
In  cases  in  which  the  trachea  has  been  completely  cut  across,  a  stitch  or 
two  on  each  side  of  the  tube  is  necessary,  in  order  to  prevent  the  wide 
separation  of  the  two  portions  that  would  otherwise  take  place,  owing 
to  the  great  mobility  of  the  larynx  and  upper  end  of  the  windpipe. 

In  order  to  lessen  the  liability  to  inflammation  of  the  lungs,  the  patient 
should  be  put  into  a  room,  the  temperature  of  which  is  raised  to  about 
80°  Fahr.,  with  a  piece  of  lightly  folded  muslin  acting  as  a  respirator 
laid  over  the  wound.  So  soon  as  the  cut  surfaces  begin  to  granulate, 
water-dressing  may  be  applied,  and  the  edge  of  the  wound  brought  into 
apposition  by  strips  of  plaster,  and  a  compress  if  necessary.  During 
the  treatment,  the  principal  danger  proceeds  from  inflammatoiy  affec¬ 
tions  of  the  chest ;  these  must  accordingl}^  be  counteracted  by  the  tem¬ 
perature  in  which  the  patient  is  placed,  and  by  as  active  anti-inflamma- 
toiy  remedies  as  his  condition  will  allow.  It  must,  however,  be  remem¬ 
bered^  that  the  mental  depression,  and  the  bodily  exhaustion  from  loss 
of  blood,  that  are  common  in  these  cases,  do  not  allow  very  active 
treatment. 

The  administration  of  food  in  these  cases  always  requires  much  atten¬ 
tion.  As  a  general  rule,  the  patient  should  be  kept  on  a  nourishing  diet, 
with  a  moderate  allowance  of  stimulants.  If,  as  not  uncommonly  hap¬ 
pens,  the  food-passage  be  opened  in  consequence  of  the  wound  extending 


FOREIGN  BODIES  IN  THE  AIR-PASSAGE. 


521 


into  the  mouth,  the  pharynx,  or  the  oesophagus,  it  is  of  course  impossible 
for  the  patient  to  swallow,  and  the  administration  of  nourishment  be¬ 
comes  very  difficult.  This  is  best  accomplished  by  means  of  an  elastic 
gum  catheter  passed  through  the  mouth  into  the  gullet  or  stomach.  This 
is  easier  than  passing  the  instrument  through  the  nose,  and  much  better 
than  introducing  it  through  the  wound.  In  this  way  a  pint  or  more  of 
the  strongest  beef-tea  or  soup,  or  Liebig’s  “  Extract  of  Meat,”  mixed 
with  two  or  three  eggs,  and  having  an  ounce  or  two  of  brandy  added  to 
it,  should  be  injected  regularly  night  and  morning,  until  the  patient  is 
able  to  swallow.  In  those  cases  in  which  the  wound  is  above  the  larynx, 
there  is  occasional  danger  of  the  supervention  of  cedema  of  the  glottis ; 
should  this  occur,  tracheotomy  may  be  necessary  to  prolong  the  patient’s 
life. 

As  consequences  of  wounds  of  the  throat,  we  occasionally  find  stric¬ 
ture  of  the  trachea,  or  aerial  fistula.  If  the  vocal  chords  have  been 
injured,  loss  of  voice  may  follow. 

Aerial  Fistula  may  sometimes  form,  owing  to  the  skin  doubling  in 
and  becoming  adherent  to  the  edges  of  the  wound  in  the  air  tube,  and 
most  frequently  occurs  when  the  cut  is  in  the  thyro-hyoid  space ;  adhe¬ 
sion  taking  place  between  the  integuments,  which  are  doubled  in,  and 
the  os  hyoicles  above  and  the  surface  of  the  thyroid  cartilage  below. 
The  same  may  occur  in  the  crico-thyroid  space,  and  indeed  at  any  part 
of  tlie  larynx  that  has  been  opened.  When  this  happens,  there  is  a  ten¬ 
dency  to  the  fistula  continuing  patent.  In  these  circumstances,  I  have 
found  the  following  operation  successful. 

The  edges  of  the  fistulous  opening  having  been  freely  pared,  and  the 
knife  passed  under  them  for  some  distance  so  as  to  detach  them  from 
the  subjacent  parts,  a  vertical  incision  is  made  through  the  louver  lip  of 
the  opening,  so  as  to  split  it  downwards.  Two  points  of  suture  are 
then  inserted  into  each  side  of  the  horizontal  incisions,  bringing  their 
edges  into  contact,  hut  the  vertebral  cut  is  left  free  for  discharges  and 
mucus  to  drain  through,  and  for  the  expired  air  to  escape,  lest  emphy¬ 
sema  occur.  Unless  this  outlet  be  afl^orded,  these  fluids  will  burst 
through  the  sutures,  and  thus  destroy  union  of  the  edges. 

It  is  not  in  every  case  that  an  aerial  flstula  can  be  safely  closed.  In 
some  instances  the  larynx  becomes  contracted  either  by  drawing  in  of 
the  wound,  or  by  thickening  of  the  mucous  membrane  above  the  artificial 
opening  to  such  an  extent  that  the  fistula  becomes  essential,  in  addition 
to  the  orifice  of  the  glottis,  for  the  purposes  of  respiration.  In  such 
circumstances,  any  attempt  at  closing  it  will  be  attended  or  followed  by 
symptoms  of  impending  asphyxia  or  collapse  of  the  lungs  ;  and  it  may 
be  necessary  to  leave  the  opening  free,  or  even,  as  happened  in  a  case 
under  my  care,  in  which  an  opening  was  left  in  the  crico-thyroid  mem¬ 
brane  of  a  girl  who  had  attempted  suicide  -by  cutting  her  throat,  to 
enlarge  the  opening  and  to  introduce  a  silver  tube  in  order  to  relieve 
the  breathing  from  the  effects  of  the  laryngeal  constriction. 

Foreign  Bodies  in  the  Air-Passage. — A  great  variety  of  sub¬ 
stances  have  been  found  in  the  air-passage:  such  as  nut-shells,  beans, 
cherry-stones,  teeth,  meat,  money,  buttons,  pins,  fish-bones,  bullets, 
pills,  pebbles,  and  pieces  of  stick.  These  foreign  bodies  are  not  intro¬ 
duced  into  the  air-passage  by  any  effort  of  deglutition,  for  no  substance 
can  be  swallowed  through  the  glottis;  but  they  are  inhaled;  thus,  if  a 
person,  whilst  holding  anything  in  his  mouth,  make  a  sudden  inspira¬ 
tion,  the  current  of  air  may  draw  it  between  the  dilated  lips  of  the 
glottis  into  the  larynx. 


522 


INJURIES  OF  THE  THROAT. 


The  symptoms  vary  according  to  the  situation  in  which  the  foreign 
body  is  lodged,  its  nature,  and  the  period  that  has  elapsed  since  the 
occurrence  of  the  accident.  The  foreign  body  may  lodge  in  one  of  the 
ventricles  of  the  larynx;  or,  if  light,  it  ma}’’  float  in  tlie  trachea,  carried 
up  and  down  by  the  movement  of  the  air  in  expiration  and  inspiration.  If 
too  heavy  for  this,  it  will  fall  into  one  or  other  of  the  primary  divisions 
of  the  trachea,  and,  as  Aston  Key  has  observed,  will  most  commonly  be 
found  in  the  right  Ibronchus.  The  explanation  of  this  has  been  pointed 
out  by  Gray,  who  states  that  on  making  a  transverse  section  of  the 
trachea,  and  taking  a  bird’s-eye  view  of  the  bifurcation,  the  septum  will 
be  seen  to  be  considerably  to  the  left  of  the  middle  line ;  so  that  any 
foreign  body  falling  down  the  trachea  would  naturally  have  a  greater 
chance  of  entering  the  right  than  the  left  bronchus,  although  the  left 
bronchus  is  a  more  direct  continuation  of  the  trachea  than  the  right. 
The  greater  size  of  the  right  bronchus  would  also  favor  the  entrance  of 
a  foreign  body  into  it.  If  the  substance  be  small,  it  may  pass  into  one 
of  the  secondary  divisions  of  the  bronchi ;  and,  if  it  continue  to  be 
lodged  here  for  a  sufficient  length  of  time,  may  make  a  kind  of  cavity 
for  itself  in  the  substance  of  the  lung,  where  it  may  either  lie  in  an 
abscess,  or  become  encysted. 

The  Symptoms  may  be  divided  into  three  stages :  1.  Obstruction, 
immediately  following  the  introduction  of  the  substance;  2.  Irritation, 
produced  by  its  presence;  and  3.  Inflammation,  coming  on  at  a  later 
period. 

1.  Symptoms  of  Obstruction. — The  immediate  symptoms  A’^ary  some¬ 
what  according  to  the  size  and  nature  of  the  body,  and  the  part  of  the 
air-tube  that  it  reaches.  In  all  cases  there  is  a  feeling  of  intense  suffo¬ 
cation,  with  great  difficulty  of  breathing,  and  violent  fits  of  spasmodic 
coughing,  often  attended  b}^  vomiting;  during  which  the  foreign  body 
may  be  expelled.  Indeed,  its  partial  entry  and  immediate  extrusion  by 
coughing  are  not  uncommon.  In  some  cases,  immediate  death  may 
ensue  at  this  period.  If  the  body  have  entered  the  air-passage  fully, 
there  is  Auolent  coughing,  with  feeling  of  suffocation  for  an  hour  or  two, 
accompanied  by  lividity  of  the  face,  great  anxiety,  and  sense  of  im¬ 
pending  death.  There  is  also  usually  pain  about  the  episternal  notch. 
The  symptoms  then  gradually  subside,  but  any  movement  on  the  part 
of  the  patient  brings  them  on  again  with  renewed  violence.  All  these 
symptoms  are  most  severe  if  the  foreign  body  remain  in  the  larynx; 
the  voice  being  then  croupy,  irregular  in  tone,  or  lost.  If  it  be  lodged 
elsewhere,  so  often  as  it  is  coughed  up,  and  strikes  against  the  interior 
of  the  larynx,  an  intense  feeling  of  suffocation  is  produced;  and  if  it 
happen  to  become  impacted  there,  sudden  death  may  result,  even  though 
it  be  not  of  sufficient  size  to  block  up  the  air-passage,  apparently  by  the 
spasm  that  is  induced.  Some  years  ago  a  boy  died  at  the  Westminster 
Hospital  before  tracheotomy  could  be  performed,  in  consequence  of  a 
flat  piece  of  walnut-shell  that  had  entered  the  trachea  being  suddenly 
coughed  up,  and  becoming  impacted  in  one  of  the  ventricles  of  the 
larynx.  The  symptoms,  during  this  period,  are  much  less  severe  when 
the  foreign  body  is  in  the  trachea  or  bronchi. 

2.  Symptoms  of  Irritation. — When  the  foreign  bod}’’  has  passed  into 
the  air-passage,  and  the  immediate  effects  produced  by  its  introduction 
have  passed  over,  another  set  of  symptoms,  dependent  on  the  irritation 
produced  by  it,  is  met  with ;  and  it  is  during  the  occurrence  of  these 
that  the  patient  is  most  generally  brought  under  the  Surgeon’s  observa¬ 
tions.  These  symptoms  are  of  two  kinds:  general  and  ausculatory. 


FOREIGN  BODIES  IN  THE  AIR-PASSAGE. 


523 


The  General  Symptoms  consist  of  occasional  fits  of  spasmodic  cough, 
accompanied  by  much  diflSculty  of  breathing,  a  feeling  of  suffocation, 
and  an  appearance  of  urgent  distress  in  the  countenance.  These  attacks 
do  not  occur  when  the  patient  is  tranquil,  but  come  on  whenever  the 
foreign  body  is  coughed  up  so  as  to  strike  the  larynx,  and  the  upper 
and  more  sensitive  parts  of  the  air-passage.  As  a  general  rule,  the 
distress  is  less,  the  lower  the  substance  is  lodged ;  the  sensibility  of  the 
lower  portion  of  the  trachea  and  that  of  the  bronchi  being  much  less 
acute  than  that  of  the  larynx  and  of  the  upper  j^art  of  the  trachea.  In 
consequence  of  the  irritation,  there  is  usually  abundant  expectoration 
of  frothy  mucus.  These  symptoms  often  remit  for  a  time,  more  particu¬ 
larly  if  the  foreign  bod}^  become  fixed.  In  some  cases,  indeed,  there 
appears  to  be  so  little  distress  some  days  after  the  accident,  that  con¬ 
siderable  doubt  may  exist  whether  any  foreign  body  really  be  lodged  in 
the  air-passage  or  in  the  lungs;  and  much  valuable  time  is  often  lost  by 
the  indisposition  of  the  Surgeon  to  adopt  active  measures. 

The  Auscultatory  Signs  depend  necessarily  upon  the  situation  of  the 
foreign  body.  If  this  be  loose  and  floating,  it  may  be  heard,  on  apply¬ 
ing  the  ear  to  the  chest,  moving  up  and  down,  and  occasionally  striking 
against  the  side  of  the  trachea.  If  it  be  fixed,  it  will  necessarily  give 
rise  to  a  certain  degree  of  obstruction  to  the  admission  of  the  air  be^^ond 
it,  perhaps  occasioning  bruits  during  its  passage.  If  it  be  impacted  in 
the  larjTix,  the  voice  will  be  hoarse  and  croupy,  and  there  will  be  a  loud 
rough  sound  in  respiration,  with  much  spasmodic  cough  and  distress  in 
breathing.  If  it  be  impacted  in  one  bronchus,  the  respiratory  murmur 
will  be  much  diminished,  or  even  absent,  in  the  corresponding  lung,  and 
probably  puerile  in  the  other ;  whilst  percussion  will  yield  an  equally 
clear  and  sonorous  sound  on  both  sides  of  the  chest,  air  being  contained 
in  the  lung  of  the  obstructed  side,  but  not  readily  passing  in  and  out. 
If  one  of  the  subdivisions  of  either  bronchus  be  occupied  by  the  foreign 
bod}^  the  entrance  of  air  will  be  prevented  in  the  corresponding  lobe  of 
that  lung,  though  it  enter  freely  every  other  part  of  the  chest.  If  the 
foreign  body  be  ajigular,  or  perforated,  peculiar  sibilant  and  whistling 
noises  may  be  heard  as  the  air  passes  over  and  through  it. 

3.  Inflammation. — After  a  foreign  body  has  been  lodged  for  a  day  or 
two  inflammation  of  the  bronchi  or  lungs  is  apt  to  be  set  up ;  in  some 
cases,  however,  this  only  occurs  after  a  considerable  time  has  elapsed, 
or,  perhaps,  not  at  all,  much  depending,  of  course,  on  the  shape  and 
character  of  the  irritant.  If  it  continue  to  lodge,  it  generally  forms  for 
itself  a  cavity  in  the  substance  of  the  lung,  whence  purulent  and  bloody 
matters  are  continually  expectorated,  until  the  patient  dies  of  phthisis 
in  the  course  of  a  few  months,  or  a  3"ear  or  two.  Occasional!}’,  however, 
the  substance  has  been  coughed  up  after  a  veiy  long  lodgement,  the 
patient  recovering.  Thus,  Tulpius  relates  a  case  in  which  a  nutshell 
W’as  coughed  up  after  being  lodged  for  seven  years ;  and  Heckster  one 
in  which  a  ducat  was  thus  brought  up  after  a  lapse  of  two  j’ears  and  a 
half ;  the  patients,  in  both  instances,  recovering.  In  other  cases  death 
may  ensue,  although  the  foreign  bod}’  is  coughed  up  ;  thus  Sue  relates 
an  instance  in  which  a  pigeon-bone  was  spat  up  seventeen  years  after 
its  introduction,  the  patient,  however,  dying  in  little  more  than  a  year 
from  marasmus. 

Prognosis. — This  depends  more  upon  the  nature  of  the  foreign  body 
and  its  size  than  on  any  other  circumstances.  If  it  be  rough,  angular, 
and  hard,  there  is  necessarily  more  risk  than  if  it  be  soluble  in  or  capa¬ 
ble  of  disintegration  by,  the  mucus  of  the  air-passage.  So  long  as  the 


524 


INJUEIES  OF  THE  THEOAT, 


foreign  body  is  allowed  to  remain,  the  patient  is  in  imminent  danger, 
either  from  immediate  and  sudden  suffocation,  or  from  inflammation  at  a 
more  remote  period. 

The  danger  depends  greatly  upon  the  length  of  time  during  which  the 
body  is  allowed  to  lodge.  Of  62  cases  which  I  collected  in  1850  (4  of 
which  had  fallen  under  my  own  observation),  I  found  the  time  that  the 
foreign  body  was  allowed  to  remain  in,  and  the  result  of  the  case,  stated 
in  49  instances. 


Period  of  Eetention. 

Less  tlian  24  lioiirs  . 

Between  24  and  48  liours 
Between  48  hours  and  1  week 
Between  1  week  and  1  month 
Between  1  month  and  3  months 
Between  3  months  and  1  year 
More  than  1  year 

Total  .... 


Number  of  Cases. 

Recovered. 

Died 

.  .  8 

6 

2 

.  4 

3 

1 

.  13 

6 

7 

.  8 

4 

4 

.  3 

3 

0 

.  6 

4 

2 

.  7 

4 

3 

.  49 

30 

19 

From  this  it  would  appear  that,  if  the  patient  escaped  the  danger  of 
the  immediate  introduction,  the  greatest  risk  occurred  between  the 
second  day  and  the  end  of  the  month,  no  fewer  than  11  patients  out  of 
21  dying  during  this  period;  and  then  that  the  mortality  diminished  until 
the  third  month,  from  which  time  it  increased  again. 

The  cause  of  death  also  varies  according  to  the  period  at  which  the 
fatal  result  takes  place.  During  the  first  twenty-four,  and,  indeed,  forty- 
eight  hours,  it  happens  from  convulsions  and  sudden  aspliyxia.  During 
the  first  few  weeks  it  is  apt  to  occur  from  inflammatory  mischief  within 
the  chest;  and  after  some  months  the  patient  will  be  carried  off  by 
marasmus  or  phthisis. 

Spontaneous  expulsion  of  the  foreign  body,  usually  in  a  violent  fit  of 
coughing,  occasionally  occurs.  Gross  of  Philadelphia  finds  that  there 
are  49  cases  on  record,  in  which  the  body  was  spontaneously  expelled, 
the  patient  recovering.  Of  these,  in  37  it  was  expelled  during  a  fit  of 
coughing.  The  period  during  which  a  foreign  substance  may  remain  in 
the  air-passage  before  it  is  spontaneously  expelled,  varies  from  a  few 
minutes  to  many  months  or  years,;  in  one  case,  a  piece  of  bone  intro¬ 
duced  at  the  age  of  three,  was  not  ejected  until  sixty  years  had  elapsed. 
In  8  cases  death  followed  the  spontaneous  expulsion. 

Treatment. — This  action  is  always  very  serious,  and  hence  requires 
prompt  and  energetic  means  to  be  used  in  order  to  save  the  patient;  and 
fortunately  the  means  at  our  disposal,  consisting  of  the  simple  operation 
of  opening  the  trachea,  and  thus  facilitating  the  expulsion  of  the  foreign 
body,  are  usually  highly  successful.  Of  60  cases  in  which  the  result 
was  noted,  I  found  that  37  lived,  and  23  died;  but  on  analyzing  these 
cases  more  closely,  it  appears  that  in  39  no  operation  was  performed ; 
the  expulsion  of  the  foreign  body  being  trusted  to  the  efforts  of  nature. 
Of  these  23  died,  and  16  lived.  In  the  remaining  21  cases,  tabulated 
below,  tracheotomy  was  performed  ;  of  these  18  lived,  and  only  3  died, 
showing  a  remarkable  success  attendant  upon  this  operation. 


Period  of  Retention. 

Less  than  24  hours  . 

Between  24  and  48  hours 
Between  48  hours  and  1  week 
Between  1  week  and  1  month 
Between  1  and  3  months 


Number  of  Cases.  Cured.  Died. 

.  3  2  1 

.  2  2  0 

.  9  8  1 

.  5  4  1 

.  2  2  0 


Total 


.  21 


18 


3 


FOREIGN  BODIES  IN  THE  AIR-PASSAGE. 


525 


Gross  has  also  given  extensive  statistics  of  the  removal  of  foreign 
bodies,  and  has  found  that  out  of  68  recorded  cases  in  which  tracheotomy 
has  been  performed,  the  operation  was  successful  in  60,  and  in  8  the 
patient  died.  In  some  cases  laryngotomy  has  been  performed  instead 
of  tracheotomy ;  and  the  foreign  body  has  been  equally  well  expelled. 
Gross  gives  13  instances  of  this,  successful  in  their  results,  and  4  in 
which  death  followed  the  operation.  Laryngo-tracheotomy  was  done  in 
13  cases ;  of  these  there  were  10  successes  and  3  deaths. 

Gross’  statistics  of  160  cases  are  as  follows: — 


Spontaneous  Expulsion  . 
Inversion  of  Body  alone 
Tracheotomy  . 
Laryngotomy  . 
Laryngo-tracheotomy 


Eecovered. 

Died. 

Total. 

.  49 

8 

57 

.  5 

0 

5 

.  60 

8 

68 

.  13 

4 

17 

.  10 

3 

13 

Emetics,  sternutatories,  and  succussion  of  the  body,  are  all  either 
useless  or  dangerous.  Inversion  of  the  body  has  succeeded  in  several 
instances,  and  might,  I  think,  be  tried  before  operation  is  had  recourse 
to,  more  particularly  if  the  foreign  body  be  a  coin,  and  be  movable  in 
the  air-passage.  Padley  caused  the  ejection  of  a  sixpenny-piece  in  this 
way  from  the  trachea  of  a  man,  and  he  recommends  the  supine  as  a  safer 
and  better  position  than  the  prone.  There  is  undoubtedly  danger,  in 
inversion,  of  the  sux^ervention  of  laiyngeal  spasm,  but  statistics  do  not 
prove  that  any  fatal  consequences  have  resulted  from  this  cause.  Should, 
however,  the  attempt  at  exx^ulsion  by  inversion  of  the  body  bring  on  an 
attack  of  laryngeal  sx^asm,  the  attempt  should  be  abandoned,  as  not  only 
useless  but  in  the  highest  degree  dangerous.  When  the  foreign  body  is 
lodged  in  the  upper  x^art  of  the  air-passage,  it  can  sometimes  be  detected 
by  laryngoscopic  examination,  and  may  be  removed  by  forcex^s,  or  such 
other  means  as  the  ingenuit}^  of  the  Surgeon  may  suggest.  Thus,  in  a 
case  recorded  by  Petre  of  Livei’x^ool,  a  x^enny  was  successfully  removed 
by  forceps  after  having  been  imx^acted  six  j^ears  in  the  larynx  of  a  boy ; 
and,  in  another  case,  in  the  Liverpool  Northern  Hosx^ital,  a  xnece  of  bone 
lying  over  one  of  the  vocal  chords  was  detected  by  the  laryngoscox^e, 
and  removed  by  means  of  long  and  shaiq^ly  curved  forcex^s. 

If,  then,  a  patient  be  seen  a  few  hours,  days,  or  weeks,  after  a  foreign 
body  has  been  introduced  into  the  air-passage,  an  examination  with  the 
laiyngoscox^e  may  be  made ;  and  if  the  body  be  within  reach,  an  attempt 
maj^  be  made  to  remove  it  by  the  mouth.  If  it  be  not  in  sight,  inversion 
of  the  body  may  be  x)ractised  ;  and  if  both  these  means  fail,  or  be  inapx)li- 
cable,  tracheotomy  ought  to  be  performed.  And  this  should  be  done, 
even  though  the  symptoms  be  not  urgent.  There  is  often  a  remission  in 
the  symptoms,  a  period  of  decexAive  securit}^,  by  which  the  Surgeon  must 
not  be  x^ut  off  his  guard.  But,  it  may  be  asked,  for  what  puiqDOse  is  the 
trachea  ox^ened  ?  Why  should  not  the  foreign  body  be  expelled  through 
the  same  ax)erture  by  which  it  has  entered  ?  The  ox^ening  in  the  trachea 
X^erforms  a  double  purpose ;  it  not  only  serves  as  a  ready  and  i:)assive 
outlet  for  the  expulsion  of  the  foreign  body,  but  also  as  a  second  breath¬ 
ing  aperture  in  the  event  of  its  escaping  through  the  glottis.  The 
advantage  of  the  opening  in  the  trachea  as  a  ready  ax^erture  of  expulsion 
is  evident  from  the  fact  that,  of  14  of  the  operated  cases  in  which  it  is 
stated  how  the  foreign  body  was  expelled,  I  find  that  in  12  it  was  ejected 
through  the  artificial  opening,  whilst  in  2  only  did  it  pass  out  through 
the  glottis. 


526 


INJURIES  OF  THE  THROAT. 


The  reason  why  the  foreign  body  usually  passes  out  of  the  artificial 
opening  in  preference  to  escaping  by  the  glottis,  is,  that  the  sides  of  the 
former  aperture  are  passive,  whereas  those  of  the  latter  are  highly  sensi¬ 
tive  and  contractile.  Before  the  operation  is  performed,  it  will  be  found 
that  the  great  obstacle  to  expulsion  is  not  only  the  sensitiveness  of  the 
larynx,  great  irritation  being  induced  when  it  is  touched  from  within, 
but  also  the  contraction  of  the  glottis,  by  the  closure  of  which  not  only 
is  the  expulsion  of  the  foreign  body  prevented,  but  respiration  is  impeded. 
Every  time  the  foreign  body  is  coughed  up  so  as  to  touch  the  interior  of 
the  larynx,  intense  dyspnoea  is  produced,  owing  to  sudden  and  involun¬ 
tary  closure  of  the  glottis,  by  which  respiration  is  entirely  prevented 
and  suffocation  threatened ;  the  expulsion  of  the  body  is  consequently 
arrested,  unless  it  were  by  chance  to  take  the  glottis  by  surprise,  and 
pass  through  it  at  once  in  the  same  way  that  it  has  entered  it,  without 
touching  its  sides.  If  there  be  a  second  breathing  aperture,  though  the 
larynx  is  equally  irritated  by  the  foreign  body,  yet  this  dyspnoea  cannot 
occur,  respiration  being  carried  on  uninterruptedly  by  one  opening, 
whilst  the  foreign  body  escapes  through  the  other ;  and  thus,  in  these 
circumstances,  it  may  pass  through  the  glottis  with  but  little  incon¬ 
venience. 

In  some  cases,  the  foreign  body  is  expelled  at  once  after  the  trachea 
has  been  opened ;  in  others,  not  until  some  hours,  days,  or  even  weeks, 
have  elapsed.  Thus,  in  Houston’s  case,  a  piece  of  stick  was  not  coughed 
up  until  ninety-seven  days  after  the  operation ;  and  in  Brodie’s  case, 
sixteen  days  elapsed  before  the  half-sovereign  came  away. 

The  expulsion  has  in  some  instances  been  facilitated  by  inverting  the 
patient,  shaking  him,  or  striking  him  on  the  back.  In  cases  in  which 
the  foreign  body  is  not  readily  expelled,  it  has  been  proposed  to  intro¬ 
duce  forceps  through  the  wound  in  the  trachea,  and  extract  it.  But, 
although  in  some  instances  this  has  succeeded,  as  in  a  case  in  which 
Walters,  of  Reigate,  removed  a  trachea-tube  that  had  accidentally  slipped 
five  inches  into  the  air-passage,  the  uncertainty  and  danger  of  such  a 
proceeding  are  so  great  that  few  Surgeons  will  be  disposed  to  attempt 
it ;  the  introduction  of  the  forceps  producing  violent  irritating  cough, 
during  which  their  points  might  readily  be  driven  through  the  bronchi, 
and  thus  wound  the  lung  or  contiguous  important  structures.  Besides 
this,  there  would  be  danger  of  seizing  the  projecting  angle  at  the  bifur¬ 
cation  of  the  bronchi  instead  of  the  foreign  body,  and  thus  injuring  the 
parts  seriously.  If  the  foreign  bod}^  be  fixed,  the  safer  plan  will  certainly 
be  to  leave  the  aperture  in  the  trachea  unclosed,  and  wait  for  the  loosening 
of  the  body  and  its  ultimate  expulsion,  which  have  hitherto  occurred  in 
all  cases  that  have  been  operated  on ;  or  its  escape  might  be  facilitated 
by  the  gentle  introduction  of  a  probe,  so  as  to  dislodge  it  if  seated  in 
either  bronchus,  though  this  should  be  done  with  great  caution  ;  or  the 
patient  may  be  inverted  and  succussed,  when  the  expulsion  may  take 
place.  Should  it  not  then  escape,  the  wound  should  be  kept  open  by 
means  of  blunt  hooks,  when,  perhaps,  it  may  be  ejected. 

Antiphlogistic  treatment  must  be  continued  during  the  whole  progress 
of  the  case.  After  the  escape  of  the  foreign  body,  the  opening  in  the 
trachea  must  be  closed. 

Scalds  of  the  Mouth,  the  Pharynx,  and  the  Glottis,  occasion¬ 
ally  occur  from  attempts  to  swallow  boiling  water ;  or  these  parts  arc 
scorched  by  the  inhalation  of  flame.  The  scalding  chieflj’’  happens  to 
the  children  of  the  poor,  who,  being  in  the  habit  of  drinking  cold  water 
from  the  spout  of  a  kettle,  inadvertently  attempt  to  take  a  draught 


527 


ASPHYXIA,  OR  APXCEA. 

from  the  same  source  when  the  w’ater  is  boiling.  The  hot  liquid  is  not 
swallowed,  but,  though  immediately  ejected,  has  scalded  the  inside  of 
the  mouth  and  pharynx,  giving  rise  to  much  inflammation,  which, 
extending  to  the  glottis,  may  produce  oedema  of  it,  and  thus  speedily 
destroy  life  by  suffocation.  In  three  cases  which  I  examined  after  death, 
there  was  no  sign  of  inflammation  below  the  glottis,  though  the  lips  of 
this  aperture  were  greatly  swollen ;  and  this  I  believe  to  be  invariably 
the  case,  the  inflammation  not  extending  into  the  interior  of  the  larynx, 
as  was  pointed  out  bj"  Marshall  Hall.  The  accident  always  reveals  itself 
by  very  evident  signs  ;  the  interior  of  the  mouth  looks  white  and  scalded, 
the  child  complains  of  great  pain,  and  difficulty  of  breathing  soon  sets 
in ;  which,  unless  efficiently  relieved,  may  terminate  in  speedy  suffoca¬ 
tion.  In  those  cases  in  which  these  parts  have  been  similarl}^  injured 
by  the  flame  produced  by  the  explosion  of  gas  or  of  fire-damp  being 
sucked  into  the  mouth,  the  same  conditions  present  themselves. 

In  the  Treatment  of  this  injur}^,  the  main  point  to  attend  to  is  to 
subdue  the  inflammation  before  it  involves  the  glottis  to  a  dangerous 
extent.  With  this  view,  leeches  should  be  freely  applied  to  the  neck,  and 
calomel  with  antimony  administered.  If  s^^mptoms  of  urgent  dj’spnoea 
have  set  in,  tracheotomy  must  be  performed  without  delay ;  and,  if  the  child 
be  not  too  young,  a  tube  must  be  introduced  into  the  aperture  so  made, 
and  kept  there  until  the  sw’elling  about  the  glottis  has  been  subdued  by 
a  continuance  of  the  anti-inflammatory  treatment.  In  the  majority  of 
the  cases,  however,  that  have  fallen  under  ray  observation,  in  wdiich  this 
operation  has  been  performed,  the  issue  has  been  a  fatal  one,  from  the 
speed}^  supervention  of  broncho-pneumonia ;  but  as  it  affords  the  only 
chance  of  life  when  the  dyspnoea  is  urgent,  it  must  be  done,  though  its 
performance  in  very  young  children  is  often  attended  by  much  difficulty, 
from  the  shortness  of  the  neck  and  the  small  size  of  the  trachea. 

ASPHYXIA,  OR  APNGGA. 

Asphyxia,  or,  as  it  is  more  correctly  termed,  Apnoea,  ma}^  arise  from 
various  causes.  The  following  classification  is  derived  from  a  table  by 
Harley. 

1.  Mechanical  Impediment  to  the  Entrance  of  Air  into  the  Lungs.  A. 
From  Accident :  either  (1)  external.,  as  in  pressure  on  the  trunk  pre¬ 
venting  expansion  of  the  chest ;  pressure  on  the  throat ;  smothering  ; 
paralysis  of  the  respirator}’-  muscles ;  penetrating  wound  of  the  chest, 
admitting  air ;  or  (2)  internal.,  as  in  obstruction  of  the  fauces  or  laiynx 
by  foreign  bodies,  or  in  constriction  of  these  parts  from  the  application 
of  irritating  fluids.  B.  From  Disease  ;  as  in  pressure  on  the  trachea  by 
an  aneurism  or  other  tumor  ;  oedema  of  the  glottis ;  obstruction  of  the 
air-passage  by  tumor ;  accumulated  mucus,  etc. 

2.  Drowning. 

3.  Absence  of  Oxygen., — nitrogen,  hydrogen,  or  some  other  harmless 
gas  being  inhaled. 

4.  Inhalation  of  Toxic  Gas  or  Vapor. — Several  of  the  conditions  above 
enumerated  as  producing  apnoea  have  been  already  described  in  the  pre¬ 
ceding  pages ;  and  others  will  be  considered  when  we  speak  of  disease 
of  and  operations  on  the  Air-passage.  In  this  place  we  will  speak  of 
the  Surgical  management  of  cases  in  which  respiration  has  been  sus¬ 
pended  by  Drowning,  Hanging,  and  the  Respiration  of  Noxious  Gases. 

The  general  subject  of  Suspended  Animation  from  these  various  causes 


528 


ASPHYXIA,  OR  APNOEA. 

cannot  be  discussed  here,  but  we  must  briefly  consider  some  points  of 
practical  importance  in  its  treatment. 

In  cases  of  Drowning^  life  is  often  recoverable,  although  the  sufferer 
ma}’  have  been  in  the  water  for  a  considerable  time ;  for,  though  im- 
mer'sednf  he  may  very  probably  not  have  been  submersed  during  the  whole 
time.  The  period  after  which  life  ceases  to  be  recoverable  in  cases  of 
submersion,  cannot  be  very  accuratel}^  estimated.  The  officers  of  the 
Royal  Humane  Society,  who  have  great  experience,  state  that  most 
generall}^  persons  are  not  recoverable  who  have  been  more  than  four  or 
five  minutes  under  water.  In  these  cases,  however,  although  submersion 
may  not  continue  for  a  longer  period  than  this,  the  process  of  asphyxia 
does ;  this  condition  not  ceasing  on  the  withdrawal  of  the  body  from 
the  water,  but  continuing  until  the  blood  in  the  pulmonary  vessels  is 
aerated,  either  by  the  spontaneous  or  artificial  inflation  of  the  lungs. 
As  several  minutes  are  most  commonly  consumed  in  withdrawing  the 
bod}"  from  the  water  and  conveying  it  to  land,  during  w’hich  time  no 
means  can  be  taken  to  introduce  air  into  the  luno-s,  we  must  regard  the 
asphyxia  as  continuing  during  the  w-hole  of  this  period  ;  occupying, 
indeed,  the  time  that  intervenes  between  the  last  inspiration  before  com¬ 
plete  submersion,  and  the  first  inspiration,  whether  artificial  or  sponta¬ 
neous,  after  the  removal  of  the  body  from  the  water.  The  latest  time 
at  which  life  can  be  recalled,  during  this  period,  is  the  measure  of  the 
duration  of  life  in  asphyxia.  If,  during  this  period,  the  action  of  the 
heart  should  cease  entirely,  I  believe,  with  Brodie,  that  the  circulation 
can  never  be  restored.  But,  although  we  may  put  out  of  consideration 
those  marvellous  ca^es  of  restoration  of  life  that  are  recorded  by  the 
older  writers,  and  which  are  evidently  unworthy  of  belief,  are  we  to 
reject  as  exaggerated  and  apocryphal  cases  such  as  that  by  Smethurst, 
in  which  recovery  took  place  after  ten  minutes’  submersion ;  that  by 
Douglas  of  Havre,  in  which  the  patient  was  not  only  submersed,  but 
had  actually  sunk  into,  and  was  fixed  in  the  mud  at  the  bottom  of  the 
harbor  for  from  twelve  to  fourteen  minutes  ;  or  that  by  Weeks,  in  which 
the  submersion,  on  the  testimony  of  the  most  credible  witnesses,  exceeded 
half  an  hour  ?  I  think  that  it  would  be  unphilosophical  in  the  extreme 
to  deny  the  facts  clearly  stated  by  these  gentlemen ;  the  more  so  that 
in  these,  as  in  many  other  instances  of  apparent  death  from  drowming, 
life  appears  to  have  been  prolonged  by  the  patient  falling  into  a  state  of 
syncope  at  the  moment  of  immersion.  We  must  therefore  not  despair 
of  recovery,  but  should  employ  means  of  resuscitation,  even  though 
the  body  have  been  actually  under  w"ater  a  considerable  time. 

There  are  certain  minor  means  often  employed  in  the  case  of  persons 
who  have  been  immersed  in  water,  and  are  apparently  drowned,  which 
appear  to  be  well  adapted  for  the  treatment  of  the  less  severe  forms  of 
asphyxia,  or  rather  cases  of  syncope  from  _  fright  and  immersion  in  cold 
water.  These  consist,  after  the  nose  and  mouth  have  been  cleared  of 
any  mucosities,  in  the  application  of  heat  by  means  of  a  bath  at  about 
the  temperature  of  100°  Fahr.  until  the  natural  warmth  is  restored ;  in 
the  employment  of  brisk  friction ;  and  in  passing  ammonia  to  and  fro  under 
the  nostrils.  It  is  evident  that  these  measures  can  have  no  direct  influ¬ 
ence  upon  the  heart  and  lungs,  but  can  only  act  as  general  stimuli  to 
the  system,  equalizing  the  circulation  if  it  be  still  going  on ;  and,  by 
determining  to  the  surface,  tending  to  remove  those  congestions  that 
are  not  so  much  the  consequences  of  the  asphyxia,  as  of  the  sojourn  of 
the  body  for  several  minutes  in  cold  water ;  they  would  therefore  be  of 
especial  service  during  the  colder  seasons  of  the  year.  A  hot  bath  may 


ASPHYXIA  FBOM  DROWNING. 


529 


also,  by  the  shock  it  gives,  excite  the  reflex  respiratory  movement.  With 
the  view  of  doing  this  with  a  greater  degree  of  certaint3%  cold  water 
should  be  sprinkled  or  dashed  upon  the  face  at  the  time  when  the  body 
is  immersed  in  the  hot  bath,  as  in  this  way  a  most  powerful  exciting 
influence  can  be  communicated  to  the  respiratory  muscles  ;  and  the  first 
object  of  treatment  in  all  cases  of  asphyxia — the  re-establishment  of 
respiration — would  more  rapidly  and  effectually  be  accomplished  ;  deep 
gaspings  ensuing,  by  which  the  air  would  be  sucked  into  the  remotest 
ramifications  of  the  air-cells,  arterialising  the  blood  that  had  accumu¬ 
lated  in  the  pulmonary  vessels,  enabling  it  to  find  its  way  to  the  left 
cavities  of  the  heart,  and  thus  to  excite  that  organ  to  increased  activit}^ 
These  means,  then,  are  useful  in  those  cases  of  asphyxia  in  which  the 
sufferer  has  been  but  a  short  time  submersed,  and  in  which  the  heart  is 
still  acting,  and  the  respiratory  movements  have  either  begun  of  their 
own  accord  on  the  patient  being  removed  from  the  water,  or  in  which 
they  are  capable  of  being  excited  by  the  shock  of  a  hot  bath,  aided  bj' 
the  dashing  of  cold  water  in  the  face.  At  the  same  time  the  lungs  may 
be  filled  with  pure  air,  by  compressing  the  chest  and  abdomen,  so  as  to 
expel  the  vitiated  air,  and  then  allowing  them  to  recover  their  usual 
dimensions  by  the  natural  resiliency  of  their  parietes.  A  small  quan¬ 
tity  of  air  will,  in  this  way,  be  sucked  mi  each  time  the  chest  is  allowed 
to  expand,  and  thus  the  re-establishment  of  the  natural  process  of  res¬ 
piration  may  be  much  hastened.  This  simple  mode  of  restoring  the 
vital  actions  should  never  be  omitted,  as  it  is  not  attended  with  the  least 
danger,  and  does  not  in  any  way  interfere  with  the  other  measures  em¬ 
ployed.  Marshall  Hall  has  recommended  that  the  patient  be  turned 
prone,  so  that  the  tongue  may  hang  forwards,  and  the  larynx  thus  be 
opened;  and  that  respiration  be  then  set  up  by  gentle  pressure  along 
the  back,  and  by  turning  the  patient  on  his  side  at  regular  intervals. 
If,  by  these  means,  we  succeed  in  restoring  the  proper  action  of  the  res¬ 
piratory  movements,  it  will  merely  be  necessary  to  pay  attention  to  the 
after  treatment.  Should  we,  however,  fail  in  restoring  respiration,  we 
should  have  recourse  to  other  and  more  active  measures. 

In  the  more  severe  cases  of  asph^^xia,  warmth  should  be  applied  by 
means  of  a  hot-air  bath,  by  which  not  only  the  natural  temperature  of 
the  body  may  be  re-established,  but  the  blood  in  the  capillaries  of  the 
surface  be  decarbonized.  The  most  direct  and  efficient  means,  however, 
that  we  possess  for  the  re-establishment  of  the  circulation  in  these  cases 
is  certainly  Artificial  Respiration.  In  this  way  alone  the  pulmonary 
artery  and  the  capillaries  of  the  lungs  can  be  unloaded  of  the  blood  that 
has  stagnated  in  them,  and  the  left  side  and  substance  of  the  heart  will 
be  directly  and  rapidlj’’  supplied  with  red  blood.  The  whole  value  of 
artificial  respiration  depends,  however,  upon  the  way  in  which  it  is  em¬ 
ployed.  Inflation  from  the  mouth  of  an  assistant  into  the  nostrils  or 
mouth  of  the  sufferer,  though  objectionable,  as  air  once  respired  is  not 
well  fitted  for  the  resuscitation  of  the  few  sparks  of  life  that  maybe  left 
in  the  cases  in  which  it  is  desirable  to  employ  this  means,  is  yet  in  many 
instances  the  readiest  and  indeed  the  only  mode  by  which  respiration 
can  be  set  up ;  it  should,  therefore,  always  be  employed  in  the  first  in¬ 
stance,  or  until  other  and  more  efficient  means  can  be  prepared. 

The  bellows,  if  properly  constructed  for  artificial  inflation,  so  that  the 
quantity  of  air  injected  may  be  measured,  are  no  doubt  very  useful ; 
and  if  furnished  with  Leroy’s  trachea-pipes,  or  what  is  better,  with 
nostril  tubes,  may  be  safely  employed.  About  fifteen  cubic  inches  of  air 
may  be  introduced  at  each  stroke  of  the  bellows,  and  these  should  be 
VOL.  I. — 84 


530 


ASPHYXIA,  OR  APXCEA. 

'worked  ten  or  a  dozen  times  in  a  minute.  The  lungs  should  be  emptied 
b}^  compression  of  the  chest  before  beginning  to  inflate,  and,  after  each 
inflation,  bj’  compressing  the  chest  and  abdomen ;  but  care  must  also  be 
taken  not  to  emploj^much  force,  lest  the  air-cells  be  ruptured.  Kichard- 
son  has  devised  a  pocket-bellows  for  artificial  respiration,  consisting  of 
two  elastic  hand-bellows  with  a  single  tube  for  introduction  into  the 
nostril.  A  safe,  and  at  the  same  time  a  very  efficient  mode  of  intro¬ 
ducing  pure  air  into  the  lungs,  is,  b}"  the  elastic  expansion  of  the  walls 
of  the  chest.  This  ma}^  be  effected  in  various  wa3’s  ;  either  by  means  of 
the  split  sheet,  as  recommended  bj’  Leroj’  and  Daliymple  (Fig.  203),  or 


Fig.  203. 


else  by  alternate!}’  compressing  the  chest  and  abdomen  with  the  hand, 
and  then  removing  the  pressure  so  as  to  allow  the  thorax  to  expand  by 
the  natural  resilienc}’  of  its  parietes,  and  thus,  each  time  it  expands,  to 
allow  a  certain  quantity*  of  air  to  be  sucked  into  the  bronchi.  The  method 
recommended  b}’  Silvester,  and  now  adopted  b}’  the  Koyal  Humane  So¬ 
ciety,  eflfects  this  purpose  with  great  ease  and  certaint}’.  It  is  carried 
out  in  the  following  wa}’.  The  patient  is  laid  on  a  flat  surface  on  his 
back,  with  the  head  and  shoulders  slightl}"  raised  on  a  pillow.  The  tongue 
should  be  drawn  and  held  forwards.  The  arms  are  then  to  be  grasped 
just  above  the  elbows,  and  to  be  drawn  gentl}’  and  steadil}’  upwards  until 
the}’  meet  above  the  head,  in  which  position  they  are  kept  for  two  seconds; 
they  are  then  to  be  turned  downwards,  and  to  be  pressed  for  two  seconds 
gently  and  firmly  against  the  sides  of  the  chest.  These  movements  are 
to  be  repeated  deliberately  about  fifteen  times  in  the  minute,  until 
natural  efforts  at  respiration  are  induced,  when  they  are  to  be  discon¬ 
tinued,  and  the  ordinary  means  to  promote  circulation  and  warmth  em¬ 
ployed.  The  quantity  of  air  introduced  need  not  be  large :  for,  by  the 
law  of  the  diffusion  of  gases,  if  fresh  air  be  only  introduced  into  the 
larger  divisions  of  the  bronchi,  it  will  rapidly  and  with  certainty  find  its 
way  into  the  ultimate  ramifications  of  these  tubes.  This  last  means  of 
inflation  has  the  additional  advantage  of  resembling  closely  the  natural 
jirocess  of  respiration,  which  is  one  of  expansion  from  without  inwards. 


ASPHYXIA  FROM  DEOWXIXG. 


531 


and  not,  as  when  the  month  or  bellows  are  used,  of  pressure  from  within 
outwards.  In  one  case  the  lungs  are,  as  it  were,  drawn  outwards,  the  air 
merely  rushing  in  to  fill  up  the  vacuum  that  would  otherwise  be  produced 
within  the  thorax  b}^  the  expansion  of  its  parietes  ;  in  the  other  the}^  are 
forcibly  pressed  up  from  within,  and  hence  there  is  danger  of  rupture  of 
the  air-cells. 

Inflation  of  the  Lungs  with  Oxygen  Gas  is  likely  to  be  of  great  service 
in  extreme  cases  of  asphyxia.  I  have  found  by  experiment  that  the  con¬ 
tractions  of  the  heart  can  be  excited  by  inflating  the  lungs  with  this  gas, 
when  the  introduction  of  atmospheric  air  fails  in  doing  so ;  and  there 
are  cases  on  record  in  which  resuscitation  was  effected  by  inflating  the 
lungs  with  ox3"gen,  w’hen  in  all  probability  it  could  not  have  been  effected 
with  any  other  means.  In  m3"  Essay  on  “  Asph3’xia”  will  be  found  a  case 
of  resuscitation,  in  which  ox3"gen  was  successfull3"  administered  by  Weeks 
after  the  asjDhyxia  had  continued  three-quarters  of  an  hour. 

Whatever  means  of  resuscitation  are  adopted,  the3"  should  be  continued 
for  at  least  three  or  four  hours,  even  though  no  signs  of  life  show-  them¬ 
selves  ;  and  after  ordinaiy  respiration  has  been  re-established,  the  patient 
should  be  kept  quiet  in  bed  for  some  hours. 

The  danger  of  the  supervention  of  Secondary  Asphyxia  after  recovery 
has  apparentl3^  taken  place  is  much  increased,  and  indeed  is  usually 
brought  about,  b3"  some  effort  on  the  part  of  the  patient  that  tends  to  em¬ 
barrass  the  partially  restored  action  of  the  heart  and  lungs.  The  patient, 
being  to  all  appearances  resuscitated,  is  allowed  to  get  up  and  walk  home, 
when  the  S3"mptoms  of  asph3’xia  speedily  return.  Should  S3"mptoms  of 
secondaiy  asph3"xia,  such  as  stupor,  laborious  respiration,  dilatation  of 
the  pupils,  and  convulsions,  manifest  themselves,  artificial  respiration 
should  be  immediately  set  up,  and  be  maintained  until  the  action  of  the 
heart  has  been  full3"  restored.  In  these  cases  I  should,  from  the  very 
great  efficac3"  of  electricit3'  in  the  somewhat  similar  condition  resulting 
from  the  administration  of  the  narcotic  poisons,  be  disposed  to  recom¬ 
mend  slight  shocks  to  be  passed  through  the  base  of  the  brain  and  upper 
portion  of  the  spinal  cord,  so  as  to  stimulate  the  respiratoiy  tracts. 

Asplyxia  from  the  Respiration  of  Noxious  Gases,  such  as  carbonic 
acid,  is  best  treated  by  exposing  the  surface  of  the  bod3"  to  cold  air,  b3" 
dashing  cold  water  upon  the  face,  and  by  setting  up  artificial  respiration 
without  dela3",  if  the  impression  of  cold  upon  the  surface  do  not  excite 
these  actions.  There  is  a  peculiar  variet3’'  of  this  kind  of  asplyxia,  which 
is  occasionally  met  with  among  infants,  the  true  nature  of  which  was 
pointed  out  to  me  ly  Wakle3',  who,  as  coroner,  had  abundant  opportuni¬ 
ties  of  witnessing  it,  as  it  is  not  an  uncommon  cause  of  accidental  death 
amongst  the  children  of  the  poor.  It  is  that  condition  in  which  a  child 
is  said  to  have  been  overlaid ;  the  child  sleeping  with  its  mother  or  nurse, 
being  found  in  the  morning  suffocated  in  the  bed.  On  examination  no 
marks  of  pressure  will  be  found ;  but  the  right  cavities  of  the  heart  and 
the  lungs  are  gorged  with  blood,  and  the  surface  is  livid,  clearl3"  indi¬ 
cating  death  b3"  asphyxia.  That  this  accident  is  not  the  result  of  the 
mother  overlaying  her  child,  is  not  onl3"  evident  from  the  post-mortem 
appearances,  but  was  clearl3"  proved  b3"  a  melanchol3’'  case  to  which  I 
was  called  several  3"ears  ago,  in  which  a  mother,  on  waking  in  the  morn¬ 
ing,  found  her  twin  infants  l3"ing  dead,  one  on  each  side  of  her.  Here  it 
was  evident,  from  the  position  of  the  bodies,  that  she  could  not  have 
overlaid  both.  The  true  cause  of  death  is  the  inhalation  of,  and  slow 
suffocation  b3",  the  vitiated  air  which  accumulates  under  the  bedclothes 
that  have  been  drawm,  for  the  sake  of  warmth,  over  the  child’s  head.  In 


532 


ASPHYXIA,  OR  APNCEA. 


such  cases,  resuscitation  by  artificial  respiration  should  always  be 
attempted  if  auy  signs  of  life  be  left. 

In  cases  of  Hanging^  death  seldom  results  from  pure  asphyxia,  but  is 
usually  the  consequence,  to  a  certain  degree  at  least,  of  apoplexy,  and 
commonly  of  simultaneous  injury  of  the  spinal  cord.  In  these  cases, 
bleeding  from  the  jugular  vein  may  be  conjoined  with  artificial  respira¬ 
tion. 

If  there  should  be  a  difficulty  in  setting  up  artificial  respiration 
through  the  mouth  or  nose,  as  is  more  especially  likely  to  happen  when 
the  patient  has  been  suffocated  by  breathing  noxious  gases,  or  in  cases 
of  hanging,  tracheotomy  or  larjmgotom}’-  should  at  once  be  performed, 
and  the  lungs  inflated  through  the  opening  thus  made  in  the  neck. 

INJURIES  OF  THE  PHARYNX  AND  (ESOPHAGUS. 

Wounds  of  the  (Esophagus  are  chiefly  met  with  in  cases  of  cut¬ 
throat,  in  which,  as  has  been  already  stated  in  treating  of  this  injury, 
they  occasion  much  difficulty-  by  interfering  with  deglutition. 

Foreign  Bodies  not  uncommonl}’^  become  impacted  in  the  pharynx 
and  oesophagus,  and  may  produce  great  inconvenience  by  their  size  or 
shape.  If  large,  as  a  piece  of  money,  or  a  lump  of  meat,  the  substance 
ma}’  become  fixed  in  the  lower  part  of  the  phar3mx  or  the  commence¬ 
ment  of  the  oesophagus,  which  is  narrowed  b}"  the  projection  of  the 
larynx  backwards,  and,  compressing  or  occluding  the  orifice  of  the 
glottis,  ma}"  asplyxiate  the  patient  at  once.  If  the  foreign  body’  go 
beyond  this  point,  it  usually  becomes  arrested  near  the  termination  of 
the  oesophagus.  When  it  is  small  or  pointed,  as  a  fish-bone,  pin,  or 
bristle,  it  ma}^  become  entangled  in  the  folds  of  mucous  membrane  that 
stretch  from  the  root  of  the  tongue  to  the  epiglottis,  or  that  lie  along 
the  sides  of  the  pharynx.  In  some  cases  it  may  even  perforate  these, 
penetrating  the  substance  of  the  larynx,  and  thus  producing  interrse 
local  irritation,  cough,  dj’spnoea,  and  suffocation.  The  foreign  bod}’,  by 
transfixing  the  coats  of  the  oesophagus,  may  seriously’  injure  some 
ireighboring  parts  of  importance.  Thus,  in  a  curious  case  admitted 
into  the  University  College  Hospital,  a  juggler,  in  attempting  to  swallow 
a  blunted  sword,  by  pushing  it  down  his  throat,  perfor-ated  the  oesopha¬ 
gus  and  wourrded  the  pericardium,  death  consequently  resulting  in  the 
‘Course  of  a  few  days. 

The  Symptoms  occasioned  by  the  impaction  of  a  foreign  body  in  the 
food-passages  are  sufliciently  evident.  The  serrsations  of  the  patient, 
^’ho  usrrally  complains  of  uneasiness  about  the  top  of  the  sternum, 
difficulty  hr  swallowing  solids,  and  perhaps  an  urgent  sense  of  suffoca¬ 
tion,  lead  to  the  detection  of  the  accident.  Should  any  doubt  exist,  the 
Surgeorr  may’,  by  irrtroducing  his  finger,  explore  nearly  the  whole  of  the 
pharynx,  and  should  examine  the  oesophagus  by  the  cautious  introduc¬ 
tion  of  a  well-oiled  probang. 

If  the  impaction  be  allowed  to  continue  unrelieved,  not  only  may 
•deglutition  and  respiration  be  seriously  interfered  with,  but  ulceration 
of  the  oesophagus  will  take  place,  and  abscess  form  either  behind  it  or 
betweerr  it  and  the  trachea ;  or  fatal  hemorrhage  may  ensue  by  perfora¬ 
tion  or  ulceration  of  neighboring  bloodvessels. 

The  Treatment  must  depend  upon  the  nature  of  the  foreign  body  and 
its  situation.  Should  it  be  large,  blocking  up  the  pharynx  so  as  to 
render  respiration  impracticable,  it  may  be  hooked  out  by  the  Surgeon’s 
fingers.  Should  asphyxia  have  been  induced,  it  may  be  necessary  to 


FOREIGN  BODIES  IN  THE  OESOPHAGUS. 


533 


perform  tracheotomy  at  once,  and  to  keep  up  artificial  respiration  until 
the  foreign  body  can  be  extracted.  If  it  be  small  or  pointed,  as  a  fish¬ 
bone  or  pin  for  instance,  though  it  have  lodged  high  up,  the  Surgeon 
will  usually  experience  great  difficulty  in  its  removal,  as  it  becomes 
entangled  between  and  is  covered  in  by  the  folds  of  the  mucous  mem¬ 
brane,  where  from  its  small  size  it  may  escape  detection.  In  these 
cases,  an  expanding  probang  will  be  found  useful.  After  it  has  been 
removed  the  patient  will  experience  for  some  time  a  pricking  sensation, 
as  if  it  were  still  fixed.  If  the  impacted  body  have  passed  low  down 
into  the  oesophagus,  the  Surgeon  must  deal  with  it  according  to  its 
nature.  If  it  be  smooth  and  soft,  as  a  piece  of  meat  for  instance,  it  may 
be  pushed  down  into  the  throat  by  the  gentle  pressure  of  the  probang. 
If,  however,  it  be  rough,  hard,  or  sharp-pointed,  as  a  piece  of  earthen¬ 
ware,  or  bone,  or  a  metallic  plate,  with  false  teeth  attached,  such  a 
procedure  would  certainly  cause  perforation  of  the  oesophagus,  and 
serious  mischief  to  the  parts  around;  in  these  circumstances,  therefore, 
an  attempt  at  extraction  should  be  made  by  means  of  long  slightly 
curved  forceps,  constructed  for  the  purpose. 

The  foreign  body  occasionally  becomes  so  firmly  impacted  in  the 
pharynx  or  oesophagus,  that  the  employment  of  any  degree  of  force  for 
extracting  it  would  be  attended  with  danger  of  perforating  the  oesophagus 
or  transfixing  the  large  vessels  of  the  neck;  in  these  circumstances  it 
may  become  necessary  to  open  the  tube  and  thus  remove  it.  The  opera¬ 
tion  of  Pharyngotomij  or  (Esophagotomy  is  seldom  called  for  ;  if  required, 
it  may  be  performed  b}''  making  an  incision  about  four  inches  in  length 
along  the  antei’ior  border  of  the  left  sterno-mastoid  muscle,  the  oesopha¬ 
gus  naturally  curving  somewhat  towards  the  left  side.  The  dissection 
must  then  be  carried  with  great  caution  between  the  carotid  sheath  and 
the  laiynx  and  trachea  in  a  direction  backwards,  the  omo-h3"oid  muscle 
having  been  divided  in  order  to  afford  room.  Care  must  be  taken  in 
this  deep  dissection  not  to  wound  either  of  the  thju'oid  arteries,  more 
especiall}’’  the  inferior  one,  which  will  be  endangered  by  carrying  the 
incisions  too  low.  When  the  pharynx  or  the  oesophagus  has  been 
reached,  a  sound  or  catheter  should  be  passed  through  the  mouth  into 
this  cavity,  and  pushed  forwards  so  that  its  point  may  cause  the  walls 
to  project,  and  thus  serve  as  a  guide  to  the  Surgeon.  This  must  then  be 
cut  upon,  and  the  aperture  thus  made  in  the  gullet  enlarged,  by  means 
of  a  probe-pointed  bistoury,  to  a  sufficient  size  to  allow  the  removal  of 
the  extraneous  substance. 

Hard  and  i^erfectly  indigestible  foreign  bodies,  such  as  artificial  teeth, 
are  sometimes  accidentally  swallowed  during  sleep  or  an  epileptic  fit, 
and,  passing  through  the  phaiynx  and  cesophagus,  drop  into  the  stomach. 
In  these  circumstances,  there  are  two  courses  open  to  the  Surgeon; 
either  to  endeavor  to  extract  the  foreign  substance,  or  to  leave  it,  and 
allow  it  to  pass,  if  possible,  per  anum.  I  think  that  the  line  of  practice 
to  be  followed  should  depend  on  whether  the  foreign  body  produce 
irritation  in  the  stomach  or  not.  If  it  irritate,  giving  rise  to  continued 
efforts  at  vomiting,  it  should,  if  possible,  be  extracted.  In  order  to  do 
this,  an  ivory-balled  probang  should  first  be  passed  in  to  ascertain  the 
situation  of  the  foreign  bod}^.  After  this  has  been  heard  and  felt,  we 
may  adopt  the  plan  successfully  employed  by  Little — who  removed  a 
hooked  plate  containing  five  artificial  teeth  from  the  stomach  of  a 
woman — of  introducing  a  “coin-catcher”  so  as  to  search  for,  secure, 
and  then  extract  it.  In  doing  this,  there  is  of  course  a  great  probability 
that  the  mass  will  be  drawn  up  sidewaj’s;  and  that  it  may,  if  broad. 


534 


INJURIES  OF  THE  CHEST. 


hitch  in  the  pharynx,  whence  it  must  be  detached  as  well  as  the  Surgeon 
can  manage  by  a  judicious  combination  of  force  and  skill.  Should  the 
foreign  body  be  small,  as  a  coin,  or  even  angular  and  sharp-pointed, 
as  a  plate  with  artificial  teeth,  and  should  it  not  irritate  the  stomach,  it 
had  better  be  left  to  pass  through  the  intestines.  When  it  is  thus  left, 
the  patient  should  neither  take  purgatives  nor  opiates.  Both  are  inju¬ 
rious  :  the  purgatives  by  increasing  the  irritation  of  the  bowels  and  the 
chance  of  their  being  wounded  by  sharp  and  projecting  points  from  the 
plate ;  the  opiates  by  arresting  its  progress.  The  better  plan  is  to  keep 
the  patient  in  bed,  perfectl}^  quiet,  and  to  give  him  an  abundance  of 
pultaceous  food.  By  adopting  this  plan  I  have  succeeded  in  getting  a 
gold  plate,  with  three  molar  teeth,  and  a  sharp  curved  clasping  hook 
at  each  end,  to  pass  without  the  slightest  difficulty  or  pain  four  days 
after  it  was  swallowed  by  a  gentleman  about  25  years  of  age.  Xo 
attempt  need  ever  be  made  to  extract  small  coins  from  the  stomach,  as 
they  will  always  easily  pass  through  the  intestinal  canal. 


CHAPTER  XXYIII. 

INJURIES  OF  THE  CHEST. 

Wounds  of  the  Chest  derive  their  principal  interest  and  importance 
from  the  concomitant  injury  of  the  lungs,  heart,  or  larger  bloodvessels. 
When  the  soft  parietes  alone  are  wounded,  the  injuiy  differs  in  nothing 
from  similar  lesions  in  other  parts  of  the  body ;  except  that  it  is  usually 
slower  in  healing.  This  is  especially  the  case  when  the  muscular  parietes 
are  furrowed  by  bullets.  If  the  Surgeon  be  in  doubt  whether  the  cavity 
of  the  chest  have  been  penetrated  or  not,  he  may  endeavor  to  ascertain 
this  point  by  careful  examination  with  the  finger ;  but  he  should  never 
introduce  a  probe ;  it  is  better  for  him  to  wait  and  to  be  guided  in  his 
opinion  bj'  the  symptoms  that  manifest  themselves,  rather  than,  by 
probing  the  wound,  to  run  the  risk  of  converting  it  into  what  he  dreads 
— a  penetrating  wound  of  the  chest. 

INJURIES  OF  THE  LUNGS. 

Contusion  of  the  Lungs  maj"  happen  from  severe  blows  on  the 
chest,  as  from  falls  from  horseback  or  kicks  in  the  side.  It  may  be  com¬ 
plicated  with  fracture  of  one  or  more  ribs,  usually  at  the  posterior  part. 
But  this  is  not  necessarily  a  concomitant  of  the  injury.  The  symptoms 
are  as  follows.  After  the  receipt  of  the  blow,  the  patient  is  seized  with 
difficulty  of  breathing,  which  is  apt  to  become  paroxj’smal,  so  as  to  re¬ 
semble  asthma.  There  is  expectoration,  at  first  of  mucus  untinged  with 
blood.  On  listening  to  the  chest,  coarse  crepitation,  with  some  dulness 
on  percussion,  will  be  found  towards  the  posterior  part  of  the  lung. 
After  some  da3’s,  or  possibly  weeks,  the  patient  is  seized  with  a  tolerably 
copious  expectoration  of  dark,  coagulated,  viscid  blood ;  and  the  sputa 
maj'  be  tinged  for  some  time  afterwards.  The  dj’spnoea  and  cough 
become  much  relieved  by  this  expectoration,  and  recovery  gradually 
takes  place. 

It  is  probable  that  in  these  cases  the  lung  is  ecclymosed  at  the  time 


INJURIES  OF  THE  LUNGS. 


535 


of  the  injury,  and  that  the  blood  extravasated  in  its  tissue  gradually 
breaks  down  when  it  is  discharged  by  coughing  in  the  viscous,  seini- 
coagulated  state  above  described — very  different  from  the  florid,  frothy 
sputum  of  recent  lung-wound. 

Rupture  of  the  Lung  from  external  violence  has  occasionally  been 
met  with,  more  commonly  with,  but  in  some  instances  without,  fracture 
of  the  ribs  or  other  sign  of  injury  to  the  thoracic  walls.  The  symptoms 
and  consequences  of  such  an  injury  closely  resemble,  indeed  are  identi¬ 
cal  with,  those  of  a  wound  of  the  lung;  there  being  expectoration  of 
frothy  blood,  pneumothorax,  perhaps  emph3^senia  and  subsequent  pneu¬ 
monia.  Though  very  dangerous,  these  injuries  are  not  necessarily  fatal; 
but  recovery  may  take  place  as  after  an  ordinary  open  wound  of  the 
lung. 

Wound  of  the  Lung  is  the  most  common  and  one  of  the  most 
serious  complications  of  injuries  of  the  chest.  It  may  occur  without 
any  external  wound,  from  the  end  of  a  broken  rib  being  driven  inwards, 
lacerating  the  pleura  and  penetrating  the  pulmonary  tissue ;  most  fre¬ 
quently,  however,  it  happens  from  a  penetrating  wound  of  the  chest,  by 
stab  or  bullet. 

The  Symptoms  are  sufficiently  well  marked.  There  is,  in  the  first  place, 
the  immediate  shock  that  usually  accompanies  the  infliction  of  a  severe 
injury,  in  this  case  amounting  to  extreme  collapse.  The  patient  is  at 
the  same  time  seized  with  considerable  difficulty  of  breathing,  the  respi¬ 
ration  being  abdominal ;  this  is  followed  by  much  tickling  and  irritating 
cough,  and  the  expectoration  of  frothy  bloody  mucus,  or  perhaps  large 
quantities  of  pure  blood.  If  there  be  an  external  opening,  the  air  may 
pass  in  and  out  during  the  act  of  breathing;  and  emph3’’sema,  pneumo¬ 
thorax,  or  pneumonia  will  speedil}^  supervene.  On  auscultating  the  chest 
immediately  after  the  infliction  of  the  injuiy,  and  before  there  is  time 
for  the  supervention  of  any  consequences,  a  loud  rough  crepitation  will 
be  distinctly  audible  at  and  around  the  seat  of  lesion. 

Complications. — The  principal  dangers  attending  a  wound  of  the  lung 
arise  from  the  Bleeding,  both  external  and  internal,  the  occurrence  of 
Hmmothorax,  Emphysema,  Pneumothorax,  Pneumonia,  and  Empyema. 

1.  The  Hemorrhage  is  usually  abundant  and  often  fatal ;  the  patient 
vomiting  or  spitting  up  a  large  quantity  of  florid  and  froth}"  blood,  by 
which  he  may  be  choked.  If  it  do  not  prove  fatal  by  the  second  day, 
this  blood}"  expectoration  generally  ceases  in  a  great  measure  in  the 
course  of  forty-eight  hours,  giving  way  to  sputa  of  a  more  rusty  cha¬ 
racter.  If  the  external  wound  be  very  free,  there  may  also  be  copious 
bleeding  from  it ;  but  not  unfrequently  the  blood  finds  its  way  into  the 
pleural  sac  rather  than  through  the  external  aperture,  and  accumulates 
in  it ;  and  death  may  arise  either  from  the  exhausting  effects  of  this 
internal  and  concealed  hemorrhage,  or  from  suffocation  through  the  pres¬ 
sure  exercised  on  the  lungs  by  the  blood  in  the  pleura.  Although  bloody 
expectoration  to  some  extent  at  least  is  an  almost  necessary  and  invari¬ 
able  accompaniment  of  a  wounded  lung,  yet  I  have  seen  a  laceration 
in  that  organ  three  inches  in  length,  occasioned  by  the  projection  of 
broken  ribs,  which  proved  fatal  on  the  seventh  day  by  hmmothorax  and 
pleuritic  effusion,  unattended  by  any  expectoration  of  blood,  external 
hemorrhage,  or  other  positive  sign  of  wound  of  the  lung.  The  blood  in 
these  cases  would  probably  be  infiltrated  into  the  loose  tissue  of  the  lung 
around  and  above  the  wound,  where  it  would  coagulate  so  as  to  offer  a 
barrier  against  its  escape  into  the  bronchi,  while  it  was  being  poured 
out  where  least  resistance  was  offered  to  it — viz.,  at  the  point  of  injury 


536 


INJUEIES  OF  THE  CHEST. 


in  the  pleura.  The  symptoms  of  this  internal  hemorrhage,  Hsemotliorax^ 
are  those  that  generally  characterize  loss  of  blood,  such  as  coldness  and 
pallor  of  the  surface,  small  weak  pulse,  and  a  tendency  to  collapse  with 
increasing  dyspnoea.  The  more  special  signs  consist  in  an  inability  to 
lie  on  the  uninjured  side,  with,  in  extreme  cases,  some  bulging  of  the 
intercostal  spaces,  and  an  ecchymosed  condition  of  the  posterior  part  of 
the  wounded  side  of  the  chest.  The  most  important  signs,  however,  are 
those  that  are  furnished  bj^  auscultation.  As  the  blood  gravitates  towards 
the  back  of  the  chest,  between  the  posterior  wall  and  the  diaphragm, 
there  will  be  gradually  increasing  dulness  on  percussion  in  this  situation, 
with  absence  of  respiratory  murmur;  the  other  portions  of  the  lung, 
however,  admitting  air  freely. 

An  ecchymosis  of  the  loins  described  by  Yalentin,  and  noticed  by 
Larry  and  others,  occasioned  by  the  filtration  of  the  blood  through  the 
wound  or  rent  in  the  pleura  costalis  into  the  areolar  tissue  of  the  chest, 
has  been  looked  upon  by  some  Surgeons  as  pathognomonic  of  hsemothorax ; 
its  importance,  however,  is  secondaiy  to  that  of  the  auscultatory  signs,  as 
in  many  cases  it  has  not  been  met  with,  and  in  others  of  non-penetrating 
wounds  of  the  chest  it  has  occurred. 

2.  Emphysema^  or  the  infiltration  of  air  into  the  areolar  tissue  of  the 
body,  and  Pneumothorax^  or  the  accumulation  of  air  in  the  cavity  of  the 
pleura,  are  not  unfrequent  complications  of  a  wounded  lung,  although 
not  by  an}^  means  invariably  met  with.  These  accidents  more  commonly 
occur  wdien  the  external  wound  is  small  and  oblique,  than  when  it  is 
large  and  direct,  and  often  happen  in  those  cases  in  which  the  lung  is 
l)unctured  by  a  fractured  rib,  without  there  being  any  external  wound. 
In  the  majority  of  cases,  emphysema  and  pneumothorax  occur  together, 
but  either  may  be  met  with  separately.  The  mechanism  of  traumatic 
emphysema  is  most  commonly  as  follows.  The  costal  pleura  being 
wounded,  and  the  lung  injured,  at  every  inspiration  a  quantity  of  air  is 
sucked  into  the  pleural  sac,  either  through  the  external  wound,  or,  if 
none  exist,  from  the  hole  in  the  lung,  thus  giving  rise  to  pneumo¬ 
thorax.  At  every  expiration,  the  air  that  thus  accumulates  in  the 
pleural  sac,  being  compressed  by  the  descent  of  the  walls  of  the  chest, 
is  pumped  into  the  areolar  tissue  around  the  edges  of  the  wound ;  and 
if  this  be  oblique  and  valvular,  being  unable  to  escape  wholly  through 
it,  it  finds  its  way  at  each  succeeding  respiration  further  into  the  large 
areolar  planes,  first  about  the  trunk  and  neck,  and  eventually,  perhaps, 
into  those  of  the  body  generally.  Though  this  is  the  w'ay  in  which 
emphysema  usually  occurs,  it  may  be  occasioned  otherwise.  Thus,  for 
instance,  I  had  once  under  my  care  a  woman  who  had  extensive  emphy¬ 
sema  of  the  areolar  tissue  of  the  trunk  from  fractured  ribs,  but  without 
any  pneumothorax,  the  lung  having  been  wounded  at  a  spot  where  it  was 
attached  to  the  walls  of  the  chest  by  old  adhesions,  and  the  air  having 
passed  through  them  into  the  areolar  tissue  of  the  body,  without  first 
entering  the  cavity  of  the  pleura.  Hilton  has  described  a  form  of 
traumatic  emphysema  that  arises  from  the  rupture  of  an  air-cell  or 
bronchus  without  any  external  wound.  The  air,  passing  into  tlie  poste¬ 
rior  mediastinum,  and  finding  its  way  along  the  nerves  and  vessels  in 
this  situation,  escapes  through  the  cervical  fascia  wdiich  closes  the  upper 
part  of  the  thorax,  and  thus  reaching  the  neck,  diffuses  itself  along  the 
sheaths  of  the  arteries  and  nerves,  along  which  it  finds  its  way  into  the 
limbs ;  its  appearance  in  which  is  first  indicated  by  its  extending  along 
the  course  of  the  vessels.  When  emphj^sema  is  complicated  with  fracture 
of  the  ribs,  and  the  air  surrounds  the  fractured  ends  of  the  bones,  I 


TRAUMATIC  PLEURISY  AND  EMPYEMA. 


587 


have  seen  extensive  suppuration  in  the  areolar  tissue,  so  that  the  broken 
parts  of  the  fractured  ribs  lay  bathed  in  pus.  This  will  occur  when  the 
emphysema  is  the  result  of  puncture  of  the  lung  by  the  broken  rib, 
without  any  wound  of  the  skin. 

The  Symptoms  of  emphysema  are  very  distinct.  There  is  a  puffy 
swelling,  pale  and  crackling  when  pressed  upon,  at  first  confined  to  the 
neighborhood  of  the  wound,  if  there  be  one  externally ;  if  not,  making 
its  appearance  opposite  the  fractured  ribs,  and  gradually  extending  over 
the  upper  part  of  the  trunk  and  neck.  To  these  parts  it  is  usually 
limited  :  in  some  cases,  however,  which  are  happily  rare,  the  swelling 
becomes  more  general,  the  body  being  blown  up  to  an  enormous  size,  the 
features  effaced,  the  movement  of  the  limbs  interfered  with,  respiration 
arrested,  and  suffocation  consequently  induced  ;  after  death,  air  has  been 
found  in  all  the  tissues,  even  under  the  serous  coverings  of  the  abdominal 
organs.  In  traumatic  pneumothorax  the  auscultatory  phenomena  are 
very  distinctly  marked ;  there  is  a  diminution  or  complete  absence  of 
the  respiratoiy  murmur  and  of  vocal  fremitus  on  the  affected  side,  with 
a  loud  tympanitic  resonance  on  percussion,  puerile  respiration  in  the 
sound  lung,  and  considerable  distress  in  breathing. 

3.  Pneumonia  is  an  invariable  sequence  of  wound  of  the  lung,  and 
constitutes  one  of  the  great  secondary  dangers  of  this  injury;  the 
inflammation  necessary  for  the  repair  of  the  wound  in  the  organ  having 
frequently  a  tendency  to  extend  to  some  distance  around  the  part 
injured,  and  not  uncommonly  to  terminate  in  abscess.  Traumatic  pneu¬ 
monia  resembles  in  all  its  symptoms,  auscultatory  as  well  as  general, 
the  idiopathic  form  of  the  disease.  There  are  the  same  crepitation, 
dulness  on  percussion,  and  tubular  breathing,  as  hepatization  advances ; 
with  rusty  sputa,  much  tinged  with  blood  in  the  early  stages.  It  differs, 
however,  from  the  idiopathic  form  in  having  less  tendency  to  diffuse 
itself  throughout  the  lung,  and  in  being  limited  to  the  neighborhood  of 
the  part,  and  to  the  side  that  has  been  injured.  Hence  it  may  occur  in 
au}^  part  of  the  lupg — the  upper  and  middle  lobes — and  only  invades  the 
base  of  the  organ  if  that  happen  to  be  the  seat  of  the  wound.  It  has 
also  a  greater  tendency  than  the  idiopathic  form  to  terminate  in  abscess, 
which,  however,  is  often  dependent  on  the  lodgement  of  some  foreign 
body,  such  as  a  piece  of  wadding  or  clothing,  in  the  substance  of  the 
organ.  Traumatic  pneumonia  is  also  usually  more  sthenic  than  that 
w'hich  arises  from  constitutional  causes,  and  is  attended  by  more  acute 
and  active  febrile  disturbance. 

4.  Pleurisy  and  Empyema _ Whenever  the  pleura  is  wounded,  whether 

it  be  by  a  fractured  rib  or  by  direct  open  wound,  and  wliether  the  lung 
be  injured  or  not,  pleurisy  necessarily  sets  in,  and  the  repair  of  the  injury 
in  the  serous  membrane  is  effected  by  the  effusion  of  lymph,  which,  in 
all  cases  in  which  the  pulmonic  pleura  is  injured,  and  hence  in  all  cases 
of  wounded  lung,  causes  adhesions  between  it  and  the  costal  pleura,  and 
thus  obliterates  to  a  certain  extent  the  serous  sac.  If  this  inflammation 
run  too  high,  if  the  constitution  be  unsound,  or  if  blood  or  a  foreign 
body’  be  lodged  in  the  cavit3^  of  the  pleura,  there  will  be  effusion  often 
to  a  very  considerable  extent.  The  effused  fluid  is  usuall}'-  turbid  serum, 
full  of  flakes  of  ljunph,  which  often  adheres  in  large  layers  to  the  inside 
of  the  chest-wall ;  it  is  generally  mixed  with  blood  from  the  wounded 
lung.  This  efiTusion  will  take  place  very  rapidl^^,  so  as  to  half  fill  one 
side  of  the  chest  in  three  or  four  days.  Eventually,  there  may  be  suppu¬ 
ration.  The  existence  of  these  effusions  of  serum  and  pus  mixed  with 
lymph  and  blood  ma^^  be  recognized  by  the  ordinary  auscultatory  signs; 


538 


INJURIES  OF  THE  CHEST. 


dulness  on  percussion  and  absence  of  respiratory  murmur  at  the  lower 
and  posterior  parts  of  the  chest,  up  to  a  level  that  has  a  gradual  tendency 
to  ascend,  and  that  varies  according  as  the  patient  is  upright  or  recumbent, 
with  segophony  at  the  upper  border  of  the  fluid,  until  at  last,  the  whole 
side  of  the  chest  being  filled  with  fluid,  there  is  complete  absence  of  all 
breath  and  voice  sounds  and  of  vocal  fremitus,  with  increase  of  size  on 
measurement,  bulging  of  the  intercostal  spaces,  compression  of  the  lung 
against  the  spine ;  and,  if  the  left  pleura  be  filled,  displacement  of  the 
heart  towards  the  right  side ;  if  the  right  pleura  be  the  seat  of  the 
accumulation,  descent  of  the  liver  below  its  normal  level.  When  the 
pleuritic  effusion  and  extravasation  reach  such  a  pitch  as  this,  there  is 
necessarily  great  dyspnoea,  and  death  will  usually  speedily  ensue. 

Collapse  of  the  Lung  in  wounds  of  the  chest,  consequent  upon  the 
action  of  the  atmospheric  pressure  on  the  outside  of  the  organ,  has  been 
more  frequently  spoken  about  than  seen.  The  chest  may  be  largely 
opened,  and  the  full  pressure  of  the  atmosphere  allowed  to  act  on  the 
outer  surface  of  the  lung,  and  yet  no  collapse  of  this  organ  takes  place. 
The  lung  in  such  cases  may  be  seen  rising  and  falling  at  the  bottom  of 
the  wound.  When  collapse  of  the  lung  occurs  in  the  early  stages,  it  is, 
I  believe,  owing  to  compression  by  the  air  sucked  into  the  cavity  of  the 
pleura  by  pneumothorax.  In  the  latter  stages,  it  ma}^  be  due  to  com¬ 
pression  by  hsemothorax  or  empyema. 

The  Prognosis  in  wounds  of  the  lungs  is  necessarily  extremely  unfa¬ 
vorable,  but  less  so  than  that  of  similar  injuries  of  most  of  the  other  vis¬ 
cera.  The  danger  will  depend  greatly  upon  the  mode  of  infliction  of  the 
wound  and  its  extent.  If  the  lung  be  wounded  by  the  sharp  end  of  a 
broken  rib,  recovery  usually  ensues.  Punctured  wounds  of  the  chest, 
penetrating  the  lungs,  are  alw'ays  very  serious  ;  but  here  the  danger  will 
depend  partly  on  the  depth  of  penetration,  partly  on  the  size  of  the  instru¬ 
ment  that  occasions  the  wound.  The  nearer  the  wound  penetrates  to 
the  root  of  the  lungs,  the  greater  is  the  danger  from  hemorrhage  by  the 
implication  of  the  larger  vascular  trunks.  Gunshot  wounds  of  the  chest 
are  far  more  dangerous  than  stabs,  owing  partly  to  the  laceration  attend¬ 
ant  on  a  bullet-wound,  but  especially  to  the  lodgement  of  the  bullet  or 
other  foreign  bodies,  that  so  commonly  occurs  in  these  injuries.  Guthrie 
states,  that  more  than  half  of  those  who  are  shot  through  the  chest  die. 
After  the  battle  of  Toulouse,  of  106  such  cases,  nearly  half  died  ;  and  of 
40  cases  at  the  Hotel  Dieu,  20  died.  Of  141  penetrating  gunshot  wounds 
of  the  chest  occurring  in  the  Crimean  War  in  the  British  army,  120  died  ; 
and  Mouat  and  Wyatt  state  that,  of  200  cases  of  penetrating  wounds  of 
the  chest  occurring  in  the  Russian  army  at  the  siege  of  Sebastopol,  and 
treated  at  Simpheropol,  onl}’’  3  recovered.  The  Russian  surgeons,  how¬ 
ever,  do  not  bleed  in  these  cases,  but  use  digitalis  instead.  Chenu  states 
that,  in  the  French  army  in  the  Crimea,  of  508  cases  of  penetrating 
wounds  of  the  chest,  467  were  fatal.  Longmore  remarks  that  the  appa¬ 
rently  great  mortality  in  the  Crimean  returns  was  largely  due  to  the 
proximity  of  the  field  hospitals  to  the  trenches,  where  the  patients  were 
wounded ;  if  they  had  been  wounded  in  the  ordinary  circumstances  of  a 
battle,  many  of  them  would  never  have  reached  an  hospital.  The  great 
danger  and  principal  cause  of  death  in  these  injuries  is  unquestionably 
the  hemorrhage  that  ensues.  This  may  prove  immediately  fatal  if  one 
of  the  larger  pulmonary  vessels  be  divided.  As  the  bleeding  is  most 
abundant  at  and  shortly  after  the  receipt  of  the  wound,  Hennen  states 
that,  if  the  patient  survive  the  third  day,  great  hopes  may  be  entertained 
of  his  recovery.  After  this  period,  the  chief  source  of  danger  is  the  occur- 


TREATMENT  OF  WOUNDS  OF  THE  LUNG. 


539 


rencc  of  inflammation  of  the  lungs  and  pleura,  the  extent  and  severity  of 
which  are  greatly  increased  in  gunshot  injuries  by  the  frequent  lodgement 
of  foreign  bodies  within  the  chest.  The  immediate  cause  of  death  at  this 
stage  is  undoubtedly  the  accumulation  of  inflammatory  effusion  in  the 
pleural  cavity,  as  the  direct  consequence  of  the  pleurisy  developed  by 
the  injury.  This  effusion  is  often  very  rapid,  and  may  prove  fatal  from 
the  fourth  to  the  eighth  day.  Emphysema  is  seldom  a  dangerous  com¬ 
plication,  though  it  may  become  so  if  very  extensive  and  allowed  to 
increase  unchecked. 

If  both  lungs  be  wounded  at  the  same  time,  the  result  is  almost  inevi- 
tabl}’’  fatal,  either  by  the  abundant  hemorrhage  suffocating  or  exhausting 
the  patient,  or  else  by  induction  of  asph3'Xia  in  consequence  of  air  being 
drawn  into  both  the  pleural  sacs,  and  thus,  by  compressing  the  lungs, 
arresting  respiration.  This,  however,  does  not  necessarily  result ;  and 
there  are  a  sufficient  number  of  cases  on  record  of  recoveries  after  stab 
or  bullet  wounds  traversing  both  sides  of  the  chest,  to  show  that  collapse 
of  the  lungs  and  consequent  asphyxia  do  not  necessarily  result  from 
this  double  injuiy,  which  indeed  has  also  been  determined  experimentally 
on  animals  by  Cruveilhier. 

The  Treatment  of  wounds  of  the  chest,  implicating  the  lungs,  must  have 
reference  to  various  sources  of  danger  that  have  just  been  indicated. 

The  Local  Treatment  is  very  simple.  If  the  wound  have  been  made 
b}’’  a  bullet,  all  foreign  bodies  that  are  within  reach  should  be  extracted. 
If  there  be  an}'  difficult}'  in  doing  this,  it  may  be  necessary  to  enlarge 
the  aperture  ;  but  the  Surgeon  must  not  go  too  deeply  or  perseveringly 
in  search  of  them,  lest  he  excite  more  irritation  than  the  foreign  body 
would.  Light  water-dressing  should  then  be  applied,  no  attempt  being 
made  to  close  the  aperture,  so  that  the  escape  of  any  extraneous  sub¬ 
stance  that  may  have  been  left,  or  of  extravasated  blood,  may  not  be 
interfered  with. 

If  the  wound  be  a  clean  puncture,  without  escape  of  air  or  much  hem¬ 
orrhage,  the  edges  may  be  brought  together  and  closed  by  means  of 
stitches,  plasters,  and  collodion,  so  that  the  bleeding  may  be  arrested, 
and  the  patient  enabled  to  breathe  with  more  ease.  Should  the  wound 
be  large  and  deep,  blood  and  air  issuing  freely  through  it  from  the  injured 
lung,  it  should  not  be  closed,  but  the  patient  should  be  laid  on  the  wounded 
side,  and  a  piece  of  water-dressing  applied,  otherwise  emphysema  or  hse- 
mothorax  will  certainly  occur.  In  either  case,  the  wall  of  the  chest  on 
the  injured  side  should  be  fixed  by  long  and  broad  strips  of  plaster,  an 
aperture  being  left  between  the  strips  opposite  to  the  seat  of  injury. 
Mount  states  that  the  best  results  have  followed  this  practice  in  the 
army. 

In  wounds  of  the  chest-walls,  the  intercostal  arteries  usually  seem  to 
escape;  or  at  least,  if  wounded,  they  do  not  often  bleed  in  a  troublesome 
manner.  Should  profuse  hemorrhage  occur  from  this  source,  I  believe 
that  the  only  safe  mode  of  arresting  it  is  to  open  up  the  wound,  and,  if 
necessary,  to  enlarge  it  so  as  to  reach  the  bleeding  vessel.  Should  this 
fail,  compression  must  be  trusted  to.  An  infinity  of  devices  have  been 
recommended  for  the  suppression  of  this  kind  of  hemorrhage;  but  they 
are  for  the  most  part  more  ingenious  than  useful  and  but  little  applicable 
to  practice,  and,  indeed,  the  complication  is  so  rare  in  chest-wounds,  that 
it  is  needless  to  describe  them. 

Wounds  of  the  internal  mammary  artery  are  rare,  considering  its  ex¬ 
posed  situation.  They  may,  however,  occur  if  the  chest  be  penetrated 
in  front  through  the  intercostal  spaces  or  costal  cartilages.  The  danger 


540 


INJURIES  OF  THE  CHEST. 


in  these  cases  is  from  the  hemorrhage  taking  place  slowly  into  the  ante¬ 
rior  mediastinum,  or  one  of  the  pleurae,  without  any  external  bleeding 
revealing  the  mischief.  If  the  wound  of  the  vessel  be  ascertained,  an 
attempt  should  be  made,  by  enlarging  the  external  aperture,  to  seize  and 
ligature  the  bleeding  ends,  cutting  directly  down  upon  them  through  the 
injured  intercostal  space;  or  the  vessel  might  even  be  followed  beneath 
one  of  the  costal  cartilages,  if  necessary,  by  cutting  through  this. 
Should  much  blood  have  already  been  extravasated,  this  must  be  removed 
through  the  external  wound,  by  the  introduction  of  a  female  catheter,  or 
by  the  application  of  a  cupping-glass  over  it,  and  the  case  then  treated 
like  one  of  effusion  into  the  chest. 

In  the  Constitutional  Treatment  of  these  injuries,  the  first  indication 
consists  in  diminishing  the  quantity  and  force  of  the  blood  circulating 
through  the  lungs,  and  thus,  by  lessening  the  impulse  of  the  heart  and 
increasing  the  tendency  for  the  blood  to  coagulate  in  the  spongy  pulmo¬ 
nary  tissue  and  smaller  vessels,  to  endeavor  to  arrest  the  hemorrhage 
from  these  organs.  The  patient  must  be  kept  lying  on  the  injured  side, 
and  have  nothing  but  ice  and  barley-water  allowed.  If  the  hemorrhage 
have  been  very  abundant,  the  collapse  and  fainting  consequent  upon  this 
ma^^  tend  to  induce  a  natural  cessation  of  the  bleeding,  which  thus  often 
spontaneously  ceases  on  the  supervention  of  syncope.  Should  the  hae¬ 
moptysis,  however,  continue  or  return  from  time  to  time,  what  should  be 
done  ?  Here  a  very  considerable  discrepancy  of  opinion  exists  amongst 
Surgeons:  the  question  at  issue  being  whether  venesection  should  be 
adopted  with  the  view  of  restraining  the  hemorrhage,  or  the  patient  be 
treated  by  rest,  low  diet,  ice,  digitalis,  and  similar  remedies.  Up  to  the 
close  of  the  Crimean  war,  the  most  experienced  Surgeons  were  unanimous 
in  their  opinion,  that  the  patient’s  safety  lies  in  free  and  repeated  vene¬ 
section.  John  Bell,  Hennen,  and  Guthrie,  all  concur  in  urging  the  neces¬ 
sity  of  free  venesection  so  as  to  keep  down  the  action  of  the  heart  and 
arteries.  Whenever  this  rises  and  the  cough  or  haemoptysis  returns, 
recourse  should  be  had  to  the  lancet.  In  the  Crimean  campaign,  Macleod 
states,  that  “  those  cases  did  best  in  which  early,  active,  and  repeated 
bleedings  were  had  recourse  to:”  In  the  official  Report  of  the  Medical 
and  Surgical  History  of  the  War  in  the  Crimea,  venesection  is  advocated 
with  equal  decision  as  a  means  of  arresting  hsemoj^tysis.  The  writers 
state :  “  When  haemoptysis  to  any  considerable  or  dangerous  extent  is 
present,  venesection  for  the  rapid  induction  of  syncope  seems  not  only 
allowable,  but  seems  to  afford  the  only  chance  of  safety,  and  may  even 
require  to  be  repeated.”  However  paradoxical  or  even  irrational  it 
might  at  first  sight  appear  to  endeavor  to  restrain  one  hemorrhage  by 
establishing  another,  yet  the  practice  seemed  established  as  the  result  of 
experience,  and  its  good  effects  could  be  explained  by  the  sudden  induc¬ 
tion  of  syncope  by  the  venesection,  giving  time  for  the  sealing  up  of  the 
pulmonary  vessels  by  the  coagulation  of  blood  within  them. 

But  although  this  was  the  practice  up  to  a  comparatively  recent  period, 
the  views  of  military  Surgeons  on  this  point  seem  now  to  have  under¬ 
gone  a  complete  change  ;  and  the  experience  derived  from  the  great 
war  of  the  rebellion  in  America  and  from  the  Maori  war  in  New  Zealand, 
has  led  to  the  promulgation  of  different  doctrines  and  the  adoption  of  a 
different  line  of  practice.  In  America,  venesection  appears  to  have  been 
generally  abandoned,  while  reliance  was  placed  on  rest,  cold,  and  opium 
for  the  suppression  of  hemorrhage;  and  this  practice  is  said  to  have 
been  generally  satisfactory.  In  New  Zeland,  Mouat  states  that  bleeding 
had  been  almost  entirely  discarded.  Longmore  says  that,  if  the  patient 


/ 


TREATMENT  OF  WOUNDS  OF  THE  LUNG. 


541 


should  survive,  the  loss  of  blood  by  venesection  seems  to  interrupt  the 
process  of  adhesion  between  the  pleural  surfaces,, and  other  reparative 
measures  adopted  b}'  nature,  while  it  induces  a  condition  favorable  to 
gangrene,  or  the  formation  of  ill-conditioned  purulent  effusions  in  large 
amount. 

In  civil  practice,  I  think  that,  if  the  patient  be  young  and  strong,  if 
the  haemoptysis  be  not  so  copious  as  immediately  to  threaten  life,  and 
the  dyspnoea  great,  relief  will  be  afforded,  and  the  chance  of  severe 
secondary  inflammation  lessened,  by  one  free  venesection.  But  I  do  not 
think  that  this  ought  to  be  repeated,  unless  at  a  later  stage,  to  combat 
inflammation  and  to  relieve  d3^spnoea  arising  from  the  engorged  state  of 
the  lung  and  right  side  of  the  heart. 

If  the  patient  survive  the  third  daj^,  the  .danger  to  be  apprehended  is 
no  longer  from  hemorrhage,  but  from  inflammation  of  the  lungs  and 
pleuritic  effusion.  Military  Surgeons  formerly  recommended  venesec¬ 
tion  as  a  means  both  of  preventing  and  of  reducing  inflammation.  In 
modern  practice,  however,  there  is  a  difference  of  opinion  :  in  the  Crimean 
war,  there  were  a  number  of  cases  of  recovery  from  lung-wounds  without 
blood-letting,  while  in  other  instances  recovery  was  apparently  greatly 
aided  by  free  venesection.  Longmore  remarks  that  “more  extended 
statistical  information,  with  careful  analysis  of  individual  cases,  is 
required  before  the  question  of  the  proper  treatment  of  chest-wounds, 
so  far  as  venesection  is  concerned,  can  be  considered  a  settled  one.” 
In  civil  practice,  in  healthy  subjects,  if  the  inflammation  be  confined  to 
the  lungs,  and  be  attended  by  much  dyspnoea,  venesection  will  often 
give  much  relief.  But  when  the  dyspnoea  arises  from  pleuritic  effusion, 
bleeding  must  necessarily  be  useless,  and  in  some  cases  w’ould  be  de¬ 
cidedly  injurious  by  still  further  weakening  the  powers  of  the  patient. 
The  inflammation  must  also  be  combated  by  a  rigid  diet,  and  b}^  the 
administration  of  salines  and  antimonials.  It  may  be  necessary,  how¬ 
ever,  to  support  the  patient’s  strength  at  the  same  time  that  means  are 
employed  to  reduce  the  inflammation.  In  fracture  of  the  ribs  with 
w’ounded  lung,  the  same  line  of  treatment  requires  to  be  adopted  ;  but 
wlien  the  accident  occurs  in  elderly  people,  we  may  advantageously  sub¬ 
stitute  calomel  and  opium,  or  ammonia  and  senega,  for  the  antimonials. 

If  extravasation  of  blood  into  the  pleura  be  going  on,  its  further 
effusion  must,  if  possible,  be  arrested  by  the  same  means  that  are  adopted 
for  the  stoppage  of  external  hemorrhage.  When  the  bleeding  has  been 
checked  in  this  way,  the  blood  must  early  be  let  out  from  the  pleural 
sac ;  for,  if  it  be  allowed  to  remain  there,  it  will  speedily  putrefy,  giving 
rise  to  extensive  formation  of  pus  in  the  cavity.  In  order  to  prevent 
this  occurrence,  the  wound  should  be  opened  freely  with  a  probe-pointed 
bistoury  at  the  fifth  or  sixth  day  after  the  injuiy,  so  that  the  blood  may 
be  discharged.  If  it  do  not  readily  come  away,  a  cupping-glass  may  be 
applied  over  the  aperture,  and  thus  it  may  be  withdrawn.  Should,  how¬ 
ever,  the  hemorrhage  continue  notwithstanding  the  employment  of  the 
means  indicated,  Guthrie  advises  that  the  wound  should  be  closed,  so 
that  the  blood  that  flows  into  tlie  pleural  sac  may,  by  accumulating  in 
this,  compress  the  lung,  and  thus  arrest  the  further  escape  of  blood  from 
the  w’ounded  vessels ;  the  patient  at  the  same  time  should  be  made  to  lie 
on  the  injured  side,  in  order  to  increase  the  pressure  exercised  upon  the 
wounded  organ.  On  the  sixth  or  eighth  day  the  chest  should  be  tapped, 
or  the  wound  opened  again,  in  order  to  evacuate  the  extravasation,  and 
prevent  its  acting  as  an  irritant  to  the  pleura,  or,  by  permanentl}^  com¬ 
pressing  and  condensing  the  lung,  rendering  this  useless. 


542 


INJURIES  OF  THE  CHEST. 


In  all  cases  of  purulent  effusion  into  the  chest,  Guthrie  advises,  with 
good  reason,  that  tapping  should  be  early  performed,  in  order  that  the 
lung  may  not  be  drawn  down  by  false  membranes  in  such  a  manner  as 
to  be  unable  to  expand,  which  would  lead  to  permanent  flattening  of  the 
side  and  impairment  of  respiration. 

If  any  extraneous  body,  such  as  a  bullet,  a  piece  of  wadding,  or  of 
clothing,  have  penetrated  too  deeply  into  the  chest  to  be  readily  extracted 
through  the  external  wound,  it  would  not  be  safe  to  make  incisions  or 
exploratoiy  researches,  with  a  view  of  extracting  it ;  for,  though  its 
presence  would  increase  the  patient’s  danger,  yet  attempts  at  extraction 
would  not  onl}^  add  to  this,  but  would  in  all  probability  be  fatal.  In 
many  cases,  bodies  so  lodged  become  surrounded  by  an  abscess,  are 
loosened,  and  eventually  are  spat  up,  or  appear  at  the  external  wound. 
In  other  cases,  they  remain  permanently  fixed  in  the  chest,  becoming 
enveloped  in  a  cj’st,  and  so  remaining  for  3^ears,  without  producing  irri¬ 
tation.  In  this  waj^,  Hennen  states,  a  bullet  has  been  lodged  in  the 
chest  for  upwards  of  twent}’’  years  ;  and  Yidal  mentions  a  man  who  lived 
for  fifteen  3’ears  with  the  broken  end  of  a  foil  in  his  chest,  which,  after 
death,  was  found  sticking  in  the  vertebrae,  and  stretching  across  to  one 
of  the  ribs. 

The  routine  system  of  bandaging  or  strapping  up  the  chest  tightly 
must  not  be  followed  in  all  cases  of  fracture  of  the  ribs.  There  are  two 
conditions  in  which  it  is  not  advisable.  The  first  is,  where  the  frag¬ 
ments  of  the  broken  rib  are  sharp  and  angular,  and,  projecting  inwards 
on  the  pleura  and  lung,  produce  pain,  distress,  and  no  slight  danger  of 
wounding  these  structures  if  pressed  down  upon  them.  Secondly,  there 
are  cases  where  the  lung  has  become  compressed  by  the  effusion  of  air, 
serum,  or  blood  into  the  pleural  sac.  In  such  cases,  tight  bandaging  of 
the  chest  will  produce  great  distress;  for,  the  lung  on  the  injured  side 
being  already  rendered  useless,  or  nearly  so,  as  a  respiratory  organ  by 
the  compression,  respiration  is  altogether  carried  on  by  the  lung  on  the 
uninjured  side.  If  the  chest  be  uniformly  ortightl}^  compressed,  the  use 
of  this  lung  is  also  interfered  with  to  such  an  extent,  that  a  semi-asphyxial 
condition  may  ensue.  In  such  cases,  rather  than  bandaging  the  whole 
chest,  the  better  plan  is  to  strap  up  only  the  injured  side  from  spine  to 
sternum,  so  as  to  restrain  its  movements  and  leave  the  sound  side  free. 

The  Treatment  of  Emphysema  consists  of  little  in  addition  to  what 
is  called  for  by  the  wounded  lung.  In  many  cases,  indeed,  the  air 
becomes  rapidly  absorbed,  without  the  necessity  of  any  local  inter¬ 
ference.  In  others,  again,  the  pressure  of  a  bandage  may  be  required. 
If,  however,  the  emph3^sema  be  so  extensive  as  to  interfere  with  respi¬ 
ration,  the  external  w^ound,  if  anj^  exist,  must  be  freely  opened,  and 
scarifications  made  into  the  areolar  tissue,  so  as  to  give  exit  to  the  air. 
I  doubt  whether  ernph^^sema  alone  can  ever  prove  fatal.  If,  however, 
both  sides  of  the  chest  be  opened,  it  is  possible  that  the  accompanying 
pneumothorax  may  so  interfere  with  the  due  expansion  of  the  lungs,  as 
to  produce  an  asph3^xial  condition  that  may  end  in  death. 

Hernia  of  the  Lung,  or  Pneumoeele. — This  is  an  extremel3^  rare 
affection.  It  consists  in  the  protrusion  of  a  portion  of  the  lung  at  some 
part  of  the  thoracic  walls,  so  as  to  form  a  tumor  under  the  skin.  It 
has  most  frequently  been  met  with  after  an  external  wound,  under  the 
cicatrix  of  which  the  hernial  swelling  has  appeared ;  but  it  has  been 
known  to  occur  from  fractured  ribs  without  any  wound,  and  even  from 
violent  straining  during  labor.  In  these  cases  it  is  probable  that,  the 
intercostal  muscles  and  costal  pleura  having  been  divided  or  ruptured, 


WOUNDS  OF  THE  PERICAEDIUM. 


543 


by  the  efforts  of  the  patient,  and  not  having  united  afterwards,  the  lung 
has,  during  expiration,  gradually  insinuated  itself  into  the  aperture  so 
formed,  until  at  last  the  hernial  tumor  has  appeared.  This  protrusion 
may  take  place  at  an}^  part  of  the  thoracic  parieties;  thus  Yelpau  has 
observed  it  in  the  supraclavicular  region  of  a  girl;  but  most  commonly 
it  occurs  on  one  or  other  side  of  the  chest.  The  tumor  may  attain  a 
large  size:  I  have  heard  Yelpeau  state  that  he  has  seen  one  half  as  large 
as  the  head.  It  does  not  appear  to  shorten  life. 

The  only  case  that  has  fallen  under  my  own  observation  is  one  that  I 
saw  in  1839,  in  Yelpeau’s  wards  at  La  Charite;  and  as  the  signs  of  the 
affection  were  well  marked  in  this  case,  I  may  briefly  relate  it,  from 
notes  taken  at  the  time.  A  man,  twenty-nine  3"ears  of  age,  left-handed, 
received  in  a  duel  a  sword-wound  at  the  inner  side  of,  and  a  little  below 
the  left  nipple ;  he  lost  a  considerable  quantity  of  blood,  but  did  not 
spit  up  an3^  The  wound  healed  in  about  a  fortnight,  shortl3"  after 
which  he  noticed  the  tumor,  for  which  he  was  admitted  three  months 
and  a  half  after  the  receipt  of  the  injuiy.  On  examination,  an  indurated 
cicatrix  about  half  an  inch  in  length  was  found  a  little  below,  and  to  the 
inner  side  of,  the  left  nipple.  On  inspiring  or  coughing,  a  soft  tumor 
of  about  the  size  of  an  egg  appeared  immediately  underneath  the  cica¬ 
trix,  which  it  raised  up;  it  subsided  under  pressure,  or  when  the  patient 
ceased  to  insjflre  or  to  cough;  and  its  protrusion  might  be  prevented  by 
pressing  the  finger  firmly  on  the  part  where  it  appeared,  wdien  a  depres¬ 
sion  was  felt  in  the  intercostal  muscles.  If  the  fingers  were  slid 
obliquely  over  the  tumor,  it  yielded  a  fine  and  distinct  crepitation, 
exactl}"  resembling  that  produced  b^-  compressing  a  health}^  lung,  and 
the  spongy  tissue  of  the  organ  could  be  distinguished.  On  applying 
the  ear,  a  fine  crackling  and  rubbing  sound  was  distinctlj^  perceived ; 
the  tumor  was  resonant  on  percussion.  The  portion  of  protruded 
lung  did  not  appear  to  re-enter  the  chest  on  expiration,  but  was  firmly 
fixed  in  its  new  situation.  No  treatment  was  adopted  in  the  case,  nor 
does  an^"  appear  admissible  in  similar  instances. 

The  onl^’  affection  with  which  a  hernia  of  the  lung  can  be  confounded, 
is  a  circumscribed  empj^ema  which  is  making  its  wa}"  through  the  walls 
of  the  chest.  Here,  however,  the  dulness  on  percussion,  and  the  absence 
of  respiratory  murmur  and  of  crackling  under  the  fingers,  will  readily 
enable  the  Surgeon  to  make  the  diagnosis. 

It  occasionally  happens  in  extensive  wounds  of  the  chest,  that  a  por¬ 
tion  of  the  lung  protrudes  during  efforts  at  expiration.  If  the  wound 
be  free,  the  protruded  lung  may  return  on  pressure  or  during  inspira¬ 
tion.  If  left  unreturned,  it  soon  becomes  livid  and  gangrenous ;  in 
these  circumstances  it  may  be  removed  by  the  knife  or  ligature;  but 
Guthrie  advises  that  the  protruded  part  should  never  be  separated 
from  the  pleura  costalis  by  which  it  is  surrounded  at  its  base,  so  that 
the  cavit}"  of  the  thorax  may  not  be  opened ;  the  wound  must  then 
be  closed  in  the  usual  wa3^ 

WOUNDS  OF  THE  HEART  AND  LARGE  YESSELS. 

Wounds  of  the  Pericardium. — The  pericardium  may  be  wounded 
with  or  without  penetration  of  the  chest,  and  with  or  without  injury  of 
the  heart.  W^ithout  wound  of  the  chest-wall,  it  may  be  lacerated  by  a 
severe  contusion  ;  with  penetration  of  the  chest-wall,  it  ma^^  be  wounded 
by  a  stab  or  by  gunshot. 

Laceration  of  the  pericardium  may  take  place  from  a  severe  blow  on 


544 


INJURIES  OF  THE  CHEST. 


the  chest.  In  this  way  I  have  seen  the  membrane  split  clown  longitudi¬ 
nally  for  two  or  three  inches,  from  contusion  received  in  a  fall. 

The  pericardium  may  be  wounded  by  a  stab  without  the  heart  being 
injured.  Thus  I  have  seen  a  wound  of  the  pericardium  in  a  young  man, 
inflicted  by  his  sweetheart  with  a  sharp-pointed  pair  of  embroidery 
scissors. 

The  pericardium  may  be  bruised  or  cut  by  an  oblique  gunshot  wound 
without  danger  to  the  heart.  This  I  have  seen  happen  from,  a  pistol- 
bullet  penetrating  the  chest  obliquely. 

In  injuries  such  as  these,  collapse  to  a  greater  or  less  extent  is  always 
met  with.  This  is  followecl  by  inflammation  ;  the  ordinary  auscultatory 
signs  of  adhesive  or  effusive  pericarditis,  such  as  friction  or  creaking, 
with  extended  dulness  on  percussion,  become  perceptible ;  and  there  are 
intense  thoracic  oppression,  dyspnoea,  and  restlessness,  with  pallor  and 
a  small  rapid  pulse. 

In  some  cases  of  wound  of  the  pericardium,  one  of  the  coronary 
vessels  may  be  injured,  and  blood  become  effused  into  the  sac,  between 
it  and  the  heart.  In  these  cases  the  interposition  of  the  la3^er  of  blood 
causes  the  heart’s  sound  to  be  weak  and  remote,  the  impulse  of  the  apex 
to  be  indistinct  or  imperceptible,  and  the  cardiac  dulness  to  be  widely 
diffused. 

The  Prognosis  of  cases  of  injur}’’  of  the  pericardium  is  necessarily 
very  unfavorable.  The  heart  may  become  choked  by  the  intrapericardial 
extravasation  of  blood  or  the  inflammatory  effusion. 

The  Treatment  of  these  cases  of  wound  of  the  pericardium  presents 
nothing  special.  It  must  be  conducted  on  those  ordinar}'-  medical 
principles  that  guide  us  in  the  management  of  similar  cases  arising  from 
other  than  traumatic  causes. 

Wounds  of  the  Heart. — The  heart  may  receive  a  wound  which 
does  not  penetrate  through  the  walls;  or  one  or  more  of  its  cavities  may 
be  opened  b}^  the  agent  that  inflicts  the  injury. .  Most  commonl}^  the 
wound  is  inflicted  by  stab  or  gunshot,  and  then  generally  no  foreign 
body  is  lodged  in  the  cardiac  cavities  or  substance.  But  in  some  in¬ 
stances  bullets,  as  well  as  pieces  of  stick,  needles,  iron  pins,  and  other 
substances,  have  been  lodged  and  encj’sted  in  the  substance  of  the 
ventricles. 

In  the  vast  majority  of  cases,  wounds  of  the  heart  are  immediately 
fatal,  but  they  are  not  necessarily  or  invariabl}^  so.  Much  will  depend 
on  whether  the}^  penetrate  or  not  into  the  cavities,  and  on  the  extent  of 
the  injury  that  the  heart  has  sustained. 

Non-penetrating  wounds  may  be  fatal  at  once  from  direct  shock  to  the 
heart ;  or  the  patient  may  survive  a  few  hours  or  days  and  then  die  of 
pericarditis ;  or  he  may  recover  and  live  for  years,  as  in  a  case  reported 
by  West  of  Birmingham,  in  which  the  man  lived  for  four  and  a  half 
3’ears.  After  death,  evidences  of  extensive  and  severe  pericarditis  were 
found,  and  there  was  a  linear  cicatrix  half  an  inch  long  in  the  anterior 
part  of  the  right  ventricle. 

Penetrating  Wounds  of  the  heart  are  almost  invariably  at  once  fatal 
from  loss  of  blood  and  shock  to  the  organ  and  system.  This  is  especially 
the  case  if  the  cavities  be  largely  opened,  or  much  of  the  heart-substance 
destroyed.  But  there  are  man}"  exceptions  to  this  general  law  of  fatality. 

Jamain  has  collected  84  cases  in  which  people  have  lived  for  consider¬ 
able  periods  after  having  received  a  wound  of  the  heart.  Of  these,  in  35 
cases  the  right  ventricle  was  wounded,  and  the  sufferers  lived  from  four 
and  a  half  hours  to  twenty-three  days.  In  19  cases  the  injury  was  to 


WOUNDS  OF  THE  HEART. 


545 


the  left  ventricle ;  and  of  these  life  was  prolonged  to  periods  varying 
from  half  an  hour  in  two  cases,  to  six  months  in  one  instance.  Both 
ventricles  were  wounded  in  five  cases,  in  patients  living  from  one  hour  to 
nine  and  a  half  months ;  the  right  auricle  in  seven  cases,  the  i^atients 
living  from  seven  hours  to  twenty  days ;  the  left  auricle  in  tw^o  cases,  in 
which  the  patients  lived  respectively  one  and  two  days.  In  many  cases, 
the  patient  has  been  known  to  w'alk  or  to  run  some  considerable  distance 
after  the  receipt  of  the  injury. 

Ollivier  and  Sanson  have  collected  29  cases  of  penetrating  wounds  of 
the  heart,  which  did  not  prove  fatal  in  the  first  forty-eight  hours  after 
the  receipt  of  the  injury.  On  analj^zing  these,  it  would  appear  that  the 
rapidity  of  death  depends  greatl}^  on  the  direction  of  the  wound  and  the 
part  of  the  organ  injured.  When  the  wound  is  parallel  to  the  axis  of  the 
heart,  it  is  not  so  speedily  fatal  as  when  in  a  transverse  direction,  and 
wounds  of  the  auricle  are  more  immediately  followed  by  death  than 
those  of  the  ventricle ;  the  irregular  contraction  of  the  diflerent  planes 
of  muscular  fibre  that  enter  into  the  formation  of  the  wall  of  the  ventricle 
tending  to  obstruct  the  free  passage  of  the  blood  through  the  wound, 
and  perhaps  to  close  it  entirely.  The  size  of  the  wound,  however,  will 
necessarily  influence  the  result  more  materiall}’  than  its  direction.  Not 
onl}’,  however,  may  a  person  live  a  considerable  time  after  having  re¬ 
ceived  a  penetrating  wound  of  the  heart,  but  there  are  many  cases  on 
record  in  which  life  has  been  prolonged  even  though  a  foreign  body  were 
lodged  in  the  cavities  or  substance  of  the  organ.  Thus  Ferrus  relates 
the  case  of  a  man  who  lived  for  twenty  da3^s  with  a  skewer  traversing  the 
heart  from  side  to  side ;  and  Roux  that  of  a  man  who  lived  twentj’-one 
days  with  a  portion  of  a  file,  with  which  he  had  stabbed  himself,  in  the 
wall  of  the  left  ventricle.  Davis  and  Steward  found  a  piece  of  wood, 
three  inches  long,  in  the  right  ventricle  of  a  bo}",  who  lived  five  weeks 
after  the  accident  had  happened ;  Carnochan  relates  a  case  in  which  the 
wounded  man  survived  eleven  da^'s  with  a  bullet  deeply  lodged  in  the 
substance  of  the  apex  of  the  heart ;  and  Latour  records  the  case  of  a 
soldier  who  lived  for  six  3'ears  after  being  wounded  with  a  musket-ball 
in  the  side,  and  in  the  right  ventricle  of  whose  heart  the  bullet  was 
found  lodged,  lying  against  the  septum. 

Ollivier,  Jamain,  West,  and  especially  Fischer,  have  collected  statistics 
with  regard  to  the  relative  frequency'  of  wounds  of  the  different  cavities 
of  the  heart.  Fischer  has  collected  452  cases,  in  wdiich  the  right  ventricle 
is  stated  to  have  been  wounded  in  123,  the  left  ventricle  in  101,  and  both 
ventricles  in  26.  In  28  cases  the  right  auricle,  and  in  13  the  left, 
was  the  seat  of  injuiy.  The  apex  of  the  heart  was  wounded  in  It. 
The  reason  of  the  frequency"  of  wound  of  the  right  ventricle  is  the 
obvious  anatomical  fact  that  it  lies  more  anteriorly  than  the  left,  and 
hence  is  more  likel}^  to  be  injured  b}"  wounds  that  penetrate  the  chest 
from  the  front — this  being  the  most  common  situation  of  wounds  that 
injure  the  heart.  According  to  Fischer,  in  258  cases  the  heart  was 
wounded  from  the  front  of  the  thorax,  in  26  from  the  abdomen,  in  11 
from  behind,  and  in  5  from  the  side. 

The  pericardium  is  necessarily  wounded  in  most  cases  of  wounds  of 
the  heart.  But  there  are  instances  on  record  in  which  a  ball  has  entered 
the  chest  and  caused  a  laceration  of  the  heart-substance  without  pene¬ 
trating  the  pericardium,  which  escaped  in  consequence  of  its  firmness  and 
fibrous  character.  Again,  as  has  already  been  stated,  the  pericardium 
alone  may  be  injured:  Fischer  has  collected  51  such  cases. 

The  Symptoms  of  a  w^ound  of  the  heart,  when  immediately  fatal,  are 
VOL.  I. — 35 


546 


INJURIES  OF  THE  CHEST. 


as  follows.  The  person  struck  springs  up  convulsivel3",  or  falls  suddenly 
prostrate ;  sometimes  with,  sometimes  without,  a  sudden  and  sharp  shriek. 
Death  results  from  hemorrhage,  which  will  be  profuse,  and  pass  out  be- 
3'ond  the  pericardium  if  the  wound  be  large  and  that  membrane  be  widely’ 
opened  ;  or  into  the  pericardium,  with  choking  of  the  heart  from  com¬ 
pression,  if  the  wound  be  small.  In  either  case,  death  is  hastened  b3r 
collapse  arising  from  shock  to  the  central  organ  of  the  circulation  itself, 
and  to  the  s^^stem  at  large  from  the  wound  of  so  important  an  organ. 

If  the  wound  be  small  and  death  be  not  immediate,  there  are  evidences 
of  great  shock  in  the  intense  depression  of  vital  power,  the  pallid  and 
anxious  countenance,  and  the  relaxation  of  the  limbs.  The  action  of  the 
heart  itself  is  tumultuous,  weak,  and  irregular;  the  pulse  is  scarcely 
perceptible ;  the  breathing  is  frightfully  embarrassed.  If  the  patient 
survive  a  few  daj’s,  these  sjmiptoms  partially  and  intermittingly  subside; 
and  the  ordinary  auscultatory  signs  of  pericarditis  come  on — friction 
and  creaking  sounds,  with  diminished  and  distant  impulse,  and  perhaps 
widel^'-spread  dulness  in  percussion.  To  these  ma}^  possibly  be  added 
evidences  of  endocardial  inflammation.  Of  these  consecutive  inflamma¬ 
tory  complications  and  of  their  consequences  the  patient  will  most 
probably*  ultimately  die,  though  perhaps  at  a  remote  period  and  after 
prolonged  suffering. 

Ruptures  of  the  Heart  from  External  violence,  without  pene¬ 
trating  wound  of  the  chest,  are  not  of  frequent  occurrence.  Gamgee 
has,  however,  collected  21  published  cases  of  this  accident.  On  analj'Zing 
these  he  finds  that,  in  at  least  one-half  of  the  cases,  the  pericardium  was 
intact;  12  of  the  ruptures  were  on  the  right,  10  on  the  left  side.  The 
right  ventricle  was  ruptured  in  8,  and  the  left  in  3  cases ;  whereas 
the  left  auricle  was  torn  in  7,  and  the  right  only  in  4  instances.  Death 
is  usually  nearly’  instantaneous,  though  there  are  instances  on  record  in 
which  the  patient  has  made  some  exertion  after  the  rupture  had  taken 
place,  and  has  even  lived  for  several  hours.  In  a  case  of  rupture  of  the 
right  auricle  recorded  by  Rust,  the  patient  survived  fourteen  hours.  In 
most  of  the  recorded  cases,  the  injury  occasioning  the  rupture  was 
directly  applied  to  the  region  of  the  heart.  But  instances  are  not 
wanting  in  which  this  organ  has  been  found  ruptured  through  one  or 
both  ventricles  or  in  one  of  the  auricles,  without  any  evidence  of  direct 
injury  in  the  cardiac  region — the  patient  having  fallen  upon  his  head  or 
shoulders,  or  having  been  mereh*  thrown  forcibl}"  to  the  ground  with 
serious  injuiy  to  the  low’er  extremities.  In  some  of  these  cases,  there 
is  reason  to  believe  that  the  rupture  was  produced  by  the  spasmodic 
violence  of  the  contractions  of  the  heart,  under  the  influence  of  great 
mental  emotion  or  fear.  The  only  case  that  has  occurred  in  mj^  practice 
was  that  of  a  man  brought  into  the  Hospital  dead,  having  fallen  from 
the  top  of  a  cart.  The  right  shoulder  was  bruised,  and  the  clavicle 
broken — showing  clearl}"  that  he  hnd  pitched  on  that  side  ;  there  was  no 
other  bruise  about  the  body,  or  evidence  that  the  wheels  had  passed 
over  him.  On  examination,  the  liver  was  found  extensively  torn,  in 
fact  smashed,  and  the  pericardium  was  distended  with  blood — there 
being  a  triangular  ragged  aperture  at  the  anterior  part  of  the  auricular 
appendage  of  the  left  auricle,  through  which  it  had  escaped. 

Wounds  of  the  Aorta  and  Vena  Cava  are  usuallj^  as  immediately 
fatal  as  those  of  the  heart  itself.  In  this  respect,  they  resemble  wounds 
of  the  auricles  rather  than  those  of  the  ventricles.  Heil  has,  however, 
recorded  a  case  in  which  the  patient  recovered  and  lived  for  a  twelve- 
month,  after  receiving  a  stab  that  penetrated  the  ascending  aorta. 


COMTUSIONS  OF  THE  ABDOMEN. 


547 


CHAPTER  XXIX. 

INJURIES  OF  THE  ABDOMEN  AND  PELVIS. 

INJURIES  OF  THE  ABDOMEN  AND  ABDOMINAL  VISCERA. 

Injuries  of  the  fibdoraen  occur  frequentl}^  They  may  be  divided  into 
Contusion  of  the  Abdomen,  with  or  without  Rupture  of  Internal  Organs; 
Non-penetrating  Wounds;  and  Penetrating  Wounds,  either  uncompli¬ 
cated,  or  conjoined  with  Injury  or  Protrusion  of  some  of  the  Organs 
contained  in  this  cavity. 

Contusions  of  the  Abdominal  Walls  from  blows  or  kicks  usually 
terminate  without  serious  inconvenience,  but  in  some  cases  are  followed 
b}"  very  acute  peritonitis,  which  may  prove  fatal. 

In  other  cases,  the  abdominal  muscles  may  be  ruptured,  although  the 
skin  may  remain  unbroken.  A  man  w^as  admitted  under  my  care  into 
the  Hospital,  having  received  a  blow  from  the  buffer  of  a  railway  carriage 
upon  his  abdomen.  He  complained  of  great  pain  at  one  spot ;  and,  on 
examination  after  death,  we  found  the  rectus  muscle  torn  across  without 
injuiy  either  to  the  integuments  or  the  peritoneum.  If  the  patient  live, 
an  injury  of  this  kind  is  apt  to  be  followed  by  atrophy  of  the  muscular 
substance,  and  perhaps  by  the  occurrence  of  a  ventral  hernia  at  a  later 
period.  Occasionally  the  contusion  is  followed  by  abscess  in  the  abdominal 
wall,  which  has  a  tendency  to  extend  widely  between  the  muscular  planes. 
These  abscesses  should  be  opened  earl}^,  lest  they  burst  into  the  perito¬ 
neal  cavity  and  occasion  fatal  inflammation. 

Buffer- Accidents. — A  contusion  of  the  abdomen  is  often  associated 
with  Rupture  of  some  of  the  Viscera.  In  military  practice  these  inter¬ 
nal  injuries  are  met  with  in  the  so-called  “wind-contusions;”  in  civil 
practice  they  commonly  result  from  blows,  kicks,  the  passage  of  a  cart¬ 
wheel  over  the  abdomen,  or  the  squeeze  of  the  body  between  the  buffers 
of  two  railway  carriages.  These  ^'‘Buffer-accidents'^  are  of  common  oc¬ 
currence  in  hospital  practice,  resulting  usually  from  the  carelessness  of 
railway  guards  and  porters,  who,  trying  to  pass  between  carriages  in 
motion,  are  caught  and  squeezed  between  the  buffers.  In  these  cases  the 
most  fearful  internal  injuries  occur,  often  without  any  external  wound. 
A  man  was  admitted  under  my  care  into  University  College  Hospital,  in 
whom  the  liver,  stomach,  spleen,  and  kidneys,  were  crushed  and  torn ; 
the  heart  was  bruised,  being  ecchymosed  on  its  surface,  and  one  of  the 
lungs  was  lacerated,  without  any  rupture  or  bruise  of  the  skin  or  frac¬ 
ture  of  the  ribs.  In  this  way  any  of  the  abdominal  organs  may  be  torn 
or  contused,  the  particular  one  injured  depending  on  the  situation  of  the 
blow.  The  organ  that  is  most  frequently  crushed  in  this  way  is  the 
liver,  owing  to  its  large  size  and  the  ready  lacerability  of  its  structure ; 
the  other  solid  organs,  such  as  the  spleen  and  kidneys,  do  not  suffer  so 
frequently  :  the  pancreas  I  have  never  seen  injured.  Among  the  hollow 
organs  the  stomach  most  commonly  suffers,  it  is  especially  likely  to  do 
so  if  struck  while  distended  by  a  meal.  Any  portion  of  the  intestinal 


548 


INJURIES  OF  THE  ABDOMEN  AND  PELVIS. 


canal  ma}’  be  lacerated.  I  have  seen  the  dnodennin,  the  ileum,  the  jeju¬ 
num,  and  the  large  intestine  ruptured  in  ditferent  cases  :  the  mesentery 
likewise  may  be  torn,  and  the  spermatic  cord  snapped  across. 

The  sufferer  usually  dies  in  the  course  of  a  few  liours,  or  at  the  utmost 
at  the  end  of  two  or  three  days  after  the  receipt  of  these  severe  injuries, 
from  hemorrhage  into  the  abdominal  cavity,  conjoined  with  shock.  It  is 
seldom  that  life  is  prolonged  sufficiently  for  peritonitis  to  be  set  up, 
though  this  is  the  chief  danger  to  be  apprehended  in  those  cases  that 
survive  the  more  immediate  effects  of  the  accident.  The  shock  of  itself 
may  prove  fatal,  though  there  be  but  little  internal  mischief  done  ;  thus, 
I  have  seen  a  man  die  collapsed  eight  hours  after  a  buffer-accident,  in 
whom  no  injuiy  was  found  except  a  small  rupture  of  mesentery,  attended 
with  but  veiy  slight  extravasation  of  blood.  The  severity  of  the  shock, 
amounting  often  to  prolonged  and  complete  collapse,  is  one  of  the  most 
remarkable  phenomena  attending  these  injuries.  It  is  difficult  to  account 
for  it,  except  in  the  supposition  that  it  is  due  to  wound  or  concussion  of 
the  great  sympathetic  nerve  and  its  large  abdominal  ganglia.  To  what¬ 
ever  cause  it  may  be  referred,  it  is  certain  that  it  is  greater  than  that 
which  follows  a  corresponding  injury,  unattended  by  loss  of  blood,  or 
any  other  part  of  the  body  except  the  central  portions  of  the  cerebro¬ 
spinal  nervous  system.  The  continuance  of  the  shock  ma}^  be  maintained, 
and  its  intensity  increased,  by  the  sjmcopal  effect  of  internal  hemorrhage, 
which,  when  the  solid  organs  are  ruptured,  is  the  most  common  cause  of 
death.  So  far  as  m3’  experience  goes,  I  should  sa}'  that  the  shock  is 
most  severe  in  injuries  of  and  about  the  stomach,  probabl}’’  from  lesion 
of  the  great  solar  plexus.  Hemorrhage  is  the  most  usual  cause  of  death 
when  the  liver  and  spleen  are  ruptured  ;  and  the  patient  usually  dies  of 
acute  peritonitis  wffien  the  intestine  has  been  torn  across.  It  does  not 
follow,  however,  that  these  injuries  are  necessaril3^  fatal.  Patients  have 
lived  after  all  the  signs  of  rupture  of  the  kidne3’s,  passing  bloody  urine, 
and  having  circumscribed  peritonitis,  and,  when  death  has  occurred  at  a 
later  period,  cicatrices  have  been  detected  in  these  organs ;  this,  indeed, 
is  nothing  more  than  has  been  met  with  in  ordinaiy  penetrating  wounds 
of  the  abdomen.  A  patient  was  admitted  under  m3"  care  into  the  Uni- 
versit3"  College  Hospital  for  a  severe  blow  upon  the  back  from  the  buffer 
of  a  railway  carriage,  followed  b3^  hmmaturia  and  other  s3"mptoms  of 
renal  injuiy ;  on  his  death  from  pneumonia  nine  weeks  after  the  accident, 
an  extravasation  of  blood,  with  the  marks  of  recent  cicatrization,  was 
found  in  the  left  kidne3^ 

Rupture  of  the  liver  is  b3^  no  means  speedil3’  or  even  necessaril3"  fatal. 
It  may  be,  and  usuall3’  is  so,  from  great  extravasation  of  blood  or  of 
bile;  but  when  this  is  not  largely  poured  out,  the  patient  may’  live  for 
some  considerable  time,  though  he  ma3"  eventually  succumb  to  traumatic 
peritonitis.  A  man  was  once  admitted  under  my  care  into  the  Uni¬ 
versity  College  Hospital,  who  had  been  crushed  between  the  buffers  of 
two  railway  carriages.  He  was  collapsed  and  apparentl3"  moribund, 
but  rallied  in  a  few  hours.  Two  da3’s  after  the  accident,  great  pain  and 
tenderness  in  the  right  h3"pochondrium  were  complained  of,  and  dulness 
on  percussion  was  found  to  extend  as  low  as  the  umbilicus.  He  became 
jaundiced,  and  there  were  S3nnptoms  of  low  peritonitis ;  these  were  fol¬ 
lowed  b3’'  great  swelling  of  the  abdomen,  which  became  t3"mpanitic  ;  the 
peritonitis  continued,  and  S3"mptoms  of  intestinal  obstruction  came  on, 
the  dulness  increasing,  with  fluctuation  in  the  flanks.  He  died  on  the 
sixteenth  day  after  the  accident,  and  on  examination  no  less  than  240 
ounces  of  bilious  fluid,  mixed  with  flakes  of  lymph,  were  found  in  the 


INTERNAL  ABDOMINAL  INJURIES. 


549 


abdominal  cavity ;  the  obstruction  being  dependent  on  the  pressure  of 
this  effusion,  and  on  the  matting  together  of  the  intestines  by  lymph. 
There  was  a  large  rent  in  the  thick  border  of  the  liver,  which  was  begin¬ 
ning  to  cicatrize. 

Injury  over  the  region  of  the  liver  followed  by  peritonitis  and  jaun¬ 
dice,  and  probably  occasioning  laceration  of  that  organ,  may  be  re¬ 
covered  from.  Of  this  I  have  had  several  instances  in  my  own  practice. 
The  following  is  a  good  example.  A  man,  about  forty  3’ears  of  age,  fell 
from  a  scaffold  to  the  ground.  In  falling,  he  struck  violently  against  a 
beam,  injuring  his  abdomen  on  the  right  side.  He  was  brought  to  the 
Hospital  in  a  state  of  collapse,  from  which  he  slowl}"  rallied.  There  was 
no  injury  but  that  of  the  abdomen,  of  which  he  complained  much,  more 
particularly  over  the  region  of  the  liver,  which  was  very  tense.  Perito¬ 
nitis  speedily  set  in,  with  great  tympanitic  distension  of  the  belly, 
vomiting  of  bilious  matter,  and  white  stools.  These  s^unptoms  continued 
many  days,  and  he  became  jaundiced.  As  the  tympanitis  subsided,  it 
was  found  that  there  was  dulness  on  percussion  in  both  flanks,  and  that 
the  fluid,  which  was  evidently  extravasated  in  the“peritoneal  cavity,  rose, 
when  he  lay  on  his  left  side,  which  he  did  habitually,  to  a  level  with  the 
umbilicus.  He  was  treated  with  opium,  and  put  on  a  very  mild  diet. 
He  gradually  but  slowly  recovered,  the  vomitings  becoming  less  frequent, 
and  eventually  ceasing,  and  the  fluid  in  the  abdomen  becoming  slowly 
absorbed,  bile  at  the  same  time  appearing  in  the  motions  ;  but  the  ten¬ 
derness  over  the  region  of  the  liver  continued  up  to  the  time  at  which  he 
left  the  Hospital,  nearly  two  months  after  the  accident.  In  this  case 
the  long  and  severe  collapse,  the  seat  of  pain  and  injury,  the  peritonitis, 
the  bilious  vomitings,  and  the  white  stools,  all  pointed  to  serious  injury 
of  the  liver  and  the  intestines  ;  and  rapid  intra-abdominal  extravasation 
could  only  be  accounted  for  by  rupture  of  that  organ. 

The  Symptoms  of  an  internal  abdominal  injury  are  often  extremel}^ 
equivocal,  and  will  necessarily  vary  according  to  the  organ  injured. 

If  the  Spleen  have  been  lacerated,  there  will  be  all  the  effects  of  severe 
shock  of  the  system,  accompanied  by  those  of  internal  hemorrhage; 
coldness,  and  pallor  of  the  surface,  a  small  and  feeble  pulse,  anxiety’  of 
countenance,  and  great  depression  of  the  vital  powers,  with  pain  at  the 
seat  of  injury,  and  perhaps  dulness  on  percussion  from  extravasated 
blood  ;  symptoms  that  speedil}'’  terminate  in  death. 

If  the  Kidneys  be  injured,  there  will  commonly  be  a  frequent  desire 
to  pass  urine,  and  this  will  be  tinged  with  blood,  often  to  a  considerable 
extent.  After  the  discharge  of  blood  ceases,  the  urine  will  become  albu¬ 
minous,  and  may  continue  so  for  a  great  length  of  time.  On  examining 
such  albuminous  urine  under  the  microscope,  it  will  generally  be  found 
to  contain  a  few  blood-corpuscles  and  possibly  some  casts  of  tubes,  with 
mucus  and  epithelial  scales,  showing  the  existence  of  inflammation  in 
the  kidney.  It  is  a  remarkable  and  important  practical  fact  that,  so  far 
as  my  experience  goes,  I  have  never  seen  albumen  in  the  urine  as  the 
result  of  renal  injury,  unless  it  had  been  preceded  by  blood.  The 
absence  of  blood  from  the  urine  must  not,  however,  be  taken  as  an  indi¬ 
cation  that  the  kidney  is  not  injured  ;  it  maj"  be  so  disorganized  as  to 
be  totally  incapable  of  secreting,  and  consequently  no  bloody  urine  flnds 
its  way  into  the  bladder.  A  man  was  admitted  into  the  Hospital  under 
my  care  for  a  buffer-injury  of  the  back;  he  passed  urine  untinged  with 
blood,  but  after  death  his  right  kidney  was  found  completely  smashed  b}" 
the  blow,  with  an  extensive  extravasation  of  blood  in  the  cellulo-adipose 
tissue  around  it ;  here  it  was  evident  that  the  disorganization  was  so 


650 


INJUEIES  OF  THE  ABDOMEN  AND  PELVIS. 


sudden  and  complete,  that  no  urine  could  find  its  way  into  the  bladder. 
In  another  case,  in  consequence  of  a  fall  from  a  window,  an  elderly  man 
died  in  the  course  of  an  hour,  having  struck  his  back  and  sustained 
several  fractures  of  the  limbs.  The  left  kidney  was  ruptured  in  a  starred 
manner,  with  extensive  extravasation  of  blood  into  the  tissues  around  it, 
but  not  a  tinge  of  blood  in  the  urine  which  was  retained  in  the  bladder. 

If  the  Liver  have  been  ruptured,  pain  over  the  region  of  that  organ, 
dulness  on  percussion  from  extravasated  blood,  and  great  collapse,  fol¬ 
lowed,  if  the  patient  live,  by  diffused  traumatic  peritonitis,  bilious 
vomitings,  white  stools,  and  jaundice,  will,  with  sufficient  precision 
indicate  the  true  nature  of  the  injury.  Bernard  has  further  shown  that 
contusions  of  the  liver  are  followed  by  traumatic  saccharine  diabetes. 

When  the  Stomach  is  ruptured,  the  nature  of  the  accident  is  usually 
revealed  by  bloody  vomiting;  and  when  the  Intestines  have  been  torn, 
by  the  admixture  of  blood  with  the  stools,  if  the  patient  live  long  enough 
to  pass  any.  These  signs,  however,  do  not  occur  in  all  cases.  A  man 
was  admitted  to  the  Hospital  under  my  care,  whose  abdomen  had  been 
squeezed  between  a  cart-wheel  and  a  lamp-post ;  during  the  five  hours 
that  he  lived  he  vomited  several  times,  bringing  up  a  meal  which  he  had 
taken  immediately  before  the  accident.  In  the  vomited  matters  there 
was  no  blood  to  be  seen ;  but  on  examination  after  death  it  was  found 
that  not  only  the  liver  and  spleen  were  ruptured,  but  the  stomach  was 
torn  almost  completely  across  near  the  pylorus. 

Emphysema  of  the  Abdominal  Wall  and  subsequently  of  the  trunk 
generally,  ma}^  result  from  the  escape  of  flatus  from  wounded  intestine 
into  the  subperitoneal  areolar  tissue,  and  thence  into  the  more  superficial 
planes.  When  this  takes  place,  the  same  doughy,  puffy,  inelastic,  crepi¬ 
tating  swelling  of  the  subcutaneous  areolar  tissue,  that  is  met  with  in 
thoracic  emphysema,  is  observed.  It  usually  commences  in  one  or  the 
other  flank,  and  may  then  creep  up  towards  the  axilla,  or  in  front  of  the 
abdominal  wall. 

As  a  diagnostic  sign,  this  form  of  emph3^sema  is  valuable  in  those 
cases  in  which  the  intestines  have  been  injured,  either  without  any  wound 
of  the  abdominal  parietes,  or,  if  there  be  wound,  without  protrusion  of 
the  injured  portion  of  gut.  In  two  of  the  cases  in  which  I  have  observed 
it,  this  condition  was  the  onl}^  positive  sign  of  intestinal  injury.  In  one 
case,  the  transverse  duodenum  had  been  ruptured  where  uncovered  by 
peritoneum,  by  a  buffer-accident ;  and,  in  the  other  the  rectum  and  meso- 
rectum  had  been  traversed  by  a  pistol-ball.  In  both  these  cases  the 
emph3^sema  was  extensive,  the  flatus  having  directly  passed  into  the 
subperitoneal  areolar  tissue.  In  other  cases  it  ma3^  in  the  first  instance 
pass  into  the  cavity  of  the  abdomen,  and  render  that  t3unpanitic,  and 
then,  as  in  thoracic  emphysema  after  pneumothorax,  escape  into  the 
areolar  tissue  at  the  edges  of  the  wound.  In  a  case  under  my  notice,  it 
occurred  after  tapping  the  bladder  through  the  rectum.  The  flatus 
escaped,  after  the  removal  of  the  cannula  on  the  sixth  da3^,  through  the 
small  aperture  in  the  walls  of  the  gut  into  the  subperitoneal  areolar 
tissue  of  the  pelvis,  thence,  through  the  sciatic  notches,  down  the  pos¬ 
terior  and  outer  part  of  the  thighs  and  the  flanks. 

The  diagnosis  of  abdominal  emphysema  from  thoracic  emph3^sema 
and  from  putrefactive  infiltration  of  air  into  the  areolar  tissue  requires 
to  be  made.  In  the  first  case,  it  may  readil3^  be  effected  by  observing  an 
absence  of  the  signs  of  thoracic  injury,  and  b3’  the  situation  of  the  em- 
ph3'sema  in  the  posterior  or  lateral  abdominal  wall,  or  around  the  lips 
of  a  wound.  From  putrefactive  infiltration  with  air  the  abdominal  em- 


WOUNDS  OF  THE  ABDOMEN. 


ool 


pbysema  is  easil}"  distinguished  by  the  cause,  and  by  the  absence  of  low 
inflammation  of  the  areolar  tissue. 

The  Treatment  of  the  various  injuries  of  the  abdomen  that  have  just 
been  described  is  very  simple.  If  the  symptoms  indicate  laceration  of 
one  of  the  viscera,  little  can  be  done  during  the  state  of  collapse  super¬ 
vening  on  the  accident,  be3^ond  the  keeping  the  patient  quiet,  and  em- 
plojdng  the  means  that  have  been  recommended  for  lessening  the  effects 
of  shock.  If  the  patient  survive  this  period,  we  must  guard  against 
peritonitis,  and  limit,  if  possible,  the  extravasation  of  blood  into  the 
abdomen,  should  there  be  indications  of  its  occurrence,  bj'  the  emplo}’- 
ment  of  treatment  that  will  presentl}'  be  described. 

Wounds  of  the  Diaphragm  ma}’’  be  occasioned  by  stabs  or  by 
gunshot  injury.  Sometimes,  however,  this  muscle  is  perforated  hy  the 
fragment  of  a  broken  rib  without  external  wound.  The  lesion,  though 
not  in  itself  mortal,  is  necessarily^  usually'  complicated  with  so  much 
visceral  injuiy  as  to  be  very’  generally  followed  by  death.  If  the  patient 
survive,  tlie  aperture  may’  be  blocked  up  by^  a  false  membrane,  to  which 
the  adjacent  lung  will  probably’ adhere ;  and  thus  the  separation  between 
the  cavities  of  the  chest  and  abdomen  will  be  maintained.  Should  this 
reparative  action  not  take  place,  a  hernial  protrusion  of  some  of  the 
abdominal  viscera  may’ take  place  into  the  pleural  cavity,  as  will  be  more 
fully  described  when  we  speak  of  “  Diaphragmatic  Hernia.” 

Wounds  of  the  Abdomen. —  Wounds  of  the  Abdominal  Wall  that 
do  not  penetrate  the  Peritoneal  Cavity^  if  uncomplicated  with  internal 
injuiy,  usually  do  well,  and  merely’  require  to  be  treated  on  ordinary’ 
principles.  If  they’  be  incised,  and  so  extensive  as  to  require  sutures, 
the  stitches  should  be  introduced  through  the  skin  alone,  never  through 
muscular  or  tendinous  structures,  the  union  of  which  could  not  be 
effected  in  this  way’;  the  parts  injured  must  also  be  relaxed  by  careful 
attention  to  position.  When  they’  are  the  result  of  gunshot  injury,  they 
suppurate  extensively’,  and  are  veiy  slow  in  healing. 

TFownds  that  penetrate  the  Cavity  of  the  Abdomen  are  of  especial 
interest,  on  account  of  the  frequency  with  which  they’  are  complicated 
with  peritonitis,  and  with  injuiy  of  the  viscera.  They  may’,  for  practical 
purposes,  be  divided  into  1,  those  that  Penetrate  the  Peritoneal  Sac, 
without  wounding  or  causing  the  protrusion  of  any’  of  the  contained 
organs ;  and  2,  those  that  are  complicated  with  Protrusion  or  Wound  of 
some  of  the  Viscera. 

1.  Penetrating  Wounds  of  the  Abdomen^  without  Visceral  Protrusion 
or  Injury^  are  often  somewhat  difficult  to  distinguish  from  simple  wounds 
of  the  abdominal  wall,  though  the  escape  of  a  small  quantity’  of  reddish 
serum  may’  reveal  the  nature  of  the  accident.  In  these  cases  the  Surgeon 
should  be  careful  not  to  push  his  examination  too  far,  by’  probing  or 
otherwise  exploring  the  wound,  lest  he  bring  about  the  veiy  injury  which 
he  is  anxious  to  avoid.  The  cavity’  of  the  peritoneum  has  often  been 
perforated  from  front  to  base  by’  bullet-wounds  or  sword-thrusts,  without 
there  being  any  sign  of  visceral  injury’.  In  the  absence  of  peritonitis  or 
other  signs  of  mischief,  the  wound  must  be  treated  as  a  simple  one  of 
the  abdominal  wall,  and  any’  complication  that  may’  occur  must  be  met 
in  the  way’  that  will  immediately’  be  described. 

2.  In  a  Penetrating  Wound  with  Pi'otrusion  or  Injury  of  the  Viscera 
the  risk  is  necessarily’  greatly’  increased ;  here  the  chief  danger  is  from 
peritonitis,  induced  either  by’  the  wound,  by’  the  extravasation  of  the 
intestinal  contents  into  the  peritoneal  cavity’,  or  by’  the  accumulation  of 
blood  in  it.  It  but  seldom  happens  that  death  results  from  hemorrhage 


552 


INJURIES  OF  THE  ABDOMEN  AND  PELVIS. 


in  these  cases,  though  this  may,  of  course,  occur  if  any  of  the  larger 
vessels  be  injured. 

Protrusion  of  uninjured  intestine^  mesentery^  or  omentum  may  take 
place  through  the  wound  in  the  abdominal  wall.  This  protruded  mass 
is  always  very  large  in  comparison  with  the  aperture  from  which  it 
escapes,  the  sides  of  which,  being  overlaid  by  it,  constrict  it  rather 
tightl}^,  so  as  to  form  a  distinct  neck  to  the  protrusion.  If  left  unre¬ 
duced,  the  mass  speedily  loses  its  polish  and  bright  color,  becoming  dull 
and  livid  from  congestion  ;  it  them  inflames,  and  soon  becomes  gangre¬ 
nous  from  the  pressure  exercised  upon  it  by  the  sides  of  the  aperture 
through  which  it  has  passed. 

In  many  cases  the  protruded  intestine  is  wounded.  The  existence  of 
this  further  injury  will  readily  be  ascertained  by  the  escape  of  flatus,  or 
of  the  more  fluid  contents  of  the  gut.  The  characters  of  tUe  wound 
var}^,  as  Travers  has  pointed  out,  according  to  its  size.  If  it  be  a  mere 
puncture,  or  even  an  incision  two  or  three  lines  in  length,  eversion  or 
prolapsus  of  the  mucous  membrane  will  take  place,  so  as  to  close  it 
sufficiently  to  prevent  the  escape  of  the  contents.  If  the  aperture  be 
above  four  lines  in  length,  this  plugging  of  it  by  everted  mucous  mem¬ 
brane  canuot  take  place,  and  then  the  contents  of  the  bowel  are  more 
freely  discharged ;  but,  even  in  these  circumstances,  there  will  be  a  ten¬ 
dency  to  the  protrusion  of  the  membrane,  which  forms  a  kind  of  lip  over 
the  edge  of  the  cut. 

A  Wounded  intestine  lohich  does  not  protrude.^  but  remains  within  the 
peritoneal  sac,  presents  the  same  conditions.  In  these  cases,  how'ever, 
there  is  the  additional  danger  of  the  extravasation  of  the  intestinal  con¬ 
tents  into  the  peritoneum.  This  extravasation,  unquestionably  one  of 
the  greatest  dangers  that  can  occur  in  wounds  of  the  abdomen,  inasmuch 
as  by  its  irritating  qualities  the  feculent  matter  gives  rise  to  and  keeps 
up  the  most  intense  peritonitis,  takes  place  less  frequently  than  might 
be  expected.  For  this  there  are  several  reasons.  In  the  first  place,  as 
we  have  alread}^  seen,  if  the  w^ound  in  the  gut  be  below  a  certain  size, 
there  is  a  natural  tendency"  to  its  occlusion  by  eversion  of  the  mucous 
membrane.  Besides  this,  it  must  be  borne  in  mind  that,  though  in  ordi¬ 
nary  language  we  speak  of  the  “  cavity”  of  the  abdomen,  there  is  in 
reality  no  such  thing ;  there  being  no  empty  space  within  the  peritoneal 
sac,  but  the  wdiole  of  the  visceral  contents  of  the  abdomen  being  so 
closely  and  equably  brought  into  contact  by  the  pressure  of  the  abdomi¬ 
nal  muscles  of  the  diaphragm,  that  it  requires  some  force  for  the  intes¬ 
tinal  contents  to  overcome  this  uniform  support,  and  to  insinuate  them¬ 
selves  between  the  coils  of  contiguous  portions  of  intestine.  The 
influence  exercised  by  the  continuous  pressure  of  the  abdominal  "walls 
upon  the  intestinal  contents,  is  well  shown  by  the  greater  facility  with 
which  these  escape  from  a  portion  of  wounded  intestine  that  has  been 
protruded,  than  from  one  that  is  still  lying  within  the  abdomen.  In  the 
former  case,  feces  will  escape  from  a  much  smaller  aperture  than  in  the 
latter  instance,  in  consequence  of  the  gut  not  being  supported  on  all 
sides  by  the  uniform  pressure  to  which  it  is  subjected  with  the  abdomen. 
It  is  seldom,  indeed,  that  feces  are  extravasated  from  gut  that  is  not 
protruding,  unless  it  be  very  full  at  the  time  of  the  injury,  or  the  wound 
in  it  be  veiy  extensive.  The  influence  of  the  equable  pressure  of  the 
abdominal  contents  in  preventing  the  escape  of  feces  was  well  illustrated 
in  a  case  in  University  College  Hospital,  of  a  man  who  was  shot 
through  the  abdomen.  The  intestines,  which  contained  much  feculent 
matter,  were  traversed  by  the  bullet  in  four  places.  He  lived  twenty- 


TREATMENT  OF  WOUNDS  OF  THE  ABDOMEN.  553 


four  hours,  and  yet  no  feculent  extravasation  took  place.  In  another 
case  to  which  I  was  called,  that  of  a  ^'ornig  gentleman  who  had  been 
accidentally  shot  through  the  abdomen  with  the  ramrod  of  a  horse- 
pistol,  the  descending  colon  was  cut  completely  across,  and  the  small 
intestines  perforated  in  two  places ;  and  yet  no  extravasation  took  place, 
though  he  survived  the  accident  two  days. 

Blood  is  extravasated  more  readily  than  the  intestinal  contents  in 
wounds  of  the  abdomen.  This  is  in  a  great  measure  owing  to  the  vis  d 
tergo  in  an  artery  of  moderate  size,  such  as  one  of  the  branches  of  the 
mesenteric,  being  sufficient  to  overcome  the  equable  pressure  and  sup¬ 
port  of  the  abdominal  walls. 

Extravasations,  whether  of  feces  or  of  blood,  when  once  formed,  have 
little  tendency  to  diffuse  themselves,  but  become  localized  in  the  neigh¬ 
borhood  of  the  part  from  which  they  w^ere  originally  poured  out ;  owing, 
in  the  first  instance,  to  the  surrounding  pressure,  and,  at  a  later  period, 
to  the  deposit  of  plastic  matter  between  the  folds  of  intestine  and  the 
neighboring  viscera.  In  this  way  the  diflTusion  of  irritating  matters 
through  the  abdominal  cavit}’-  is  prevented,  and  the  likelihood  of  the 
(Xjcurrence  of  wide-spread  and  fatal  inflammation  is  much  diminished. 

The  existence  of  these  extravasations  may,  in  many  cases,  be  recog¬ 
nized  by  dulness  on  percussion  around  the  wound,  by  the  localized 
swelling  to  which  they  give  rise,  and  sometimes  by  their  escape  through 
the  external  aperture. 

Treatment. — In  the  treatment  of  penetrating  wounds  of  the  abdomen, 
we  must  first  consider  the  management  of  the  injured  parts  ;  and,  after¬ 
wards,  the  prevention  or  cure  of  the  consecutive  peritonitis. 

If  the  wound  have  not  implicated  any  of  the  abdominal  viscera.,  it 
must  be  closed  by  relaxing  the  abdominal  muscles  by  position,  by  intro¬ 
ducing  a  few  points  of  suture  through  the  integuments,  if  it  be  extensive, 
and  by  applying  a  compress  and  plaster,  supported  by  a  bandage.  The 
patient  should  then  have  a  full  dose  of  opium  ;  about  two  grains  of  solid 
opium  or  forty  minims  of  the  liquor  sedativus,  which  must  be  repeated 
in  from  four  to  six  hours,  so  that  the  effects  ma}^  be  kept  up.  I  prefer 
in  these  cases  the  solid  opium,  of  which  as  much  as  from  six  to  eight 
grains  may  be  given  in  twenty-four  hours.  He  should  be  kept  perfectly 
quiet  in  bed,  and  no  nourishment  given  for  a  few  days,  except  barley- 
water  and  ice.  The  bowels  should  not  be  opened  by  aperient  medicine, 
lest  abdominal  irritation  be  set  up,  but  oleaginous  enemata  may  be 
administered  at  the  end  of  a  week  or  ten  days. 

If  the  intestine  he  wounded  hut  not  protruding.,  we  must  endeavor  to 
limit  the  peritonitis  that  will  ensue,  and  also  to  prevent  feculent  extrava¬ 
sation.  The  patient  should  be  laid  on  the  injured  side  with  the  wound 
dependent,  so  as  to  allow  the  feces  to  escape  through  it,  if  disposed  to 
do  so.  If  the  injury  be  above  the  umbilicus,  he  must  lie  upon  his  back 
with  the  knees  drawn  up  and  bent  over  a  pillow.  Opium  must  then  be 
administered  in  the  full  doses  already  indicated,  and  repeated  in  grain 
doses  at  least  every  fourth  or  sixth  hour,  so  that  the  system  may  be 
kept  well  under  its  influence.  The  value  of  opium  in  these  cases  is  very 
great ;  it  not  only  seems  to  moderate  the  inflammation  of  the  peritoneum, 
but  is  of  the  greatest  utility  in  preventing  the  extravasation  of  feces. 
This  is  done  by  arresting  the  peristaltic  movements  of  the  intestine,  and 
thus  keeping  it  from  change  of  position.  This  arrest  of  the  intestinal 
movements  also  tends  greatly  to  the  closure  of  the  wound.  Travers  has 
shown  experimentally,  and  his  investigations  have  been  confirmed  by 
subsequent  observations  on  the  human  subject,  that  wounds  of  the  intes- 


554 


INJURIES  OF  THE  ABDOMEN  AND  PELVIS. 


tines  are  closed  by  lymph  that  is  thrown  out,  not  onl}’-  from  the  con¬ 
tiguous  peritoneal  surfaces  of  the  part  actually  injured,  but  from  that  of 
neighboring  coils ;  so  that  the  aperture  in  the  gut  becomes  permanently 
glued  and  attached  to  the  structures  in  its  vicinity.  In  order  that  this 
process  should  take  place,  it  is  necessarily  of  importance  that  the  move¬ 
ments  of  the  bowels  be  paralyzed ;  and  it  is  a  beautiful  provision  of 
nature  that  the  very  inflammation  which  closes  the  wound,  arrests  that 
peristaltic  action,  the  continuance  of  which  would  interfere  with  its 
agglutination  to,  and  closure  by,  the  neighboring  parts.  Until,  there¬ 
fore,  the  necessaiy  degree  of  inflammation  to  effect  this  is  set  up,  the 
intestinal  movements  must  be  arrested  by  opium. 

If  extravasation  of  feculent  matter  have  taken  place  into  the  abdomen, 
an  attempt  may  be  made  to  facilitate  its  escape  externally  by  removing 
the  stitches  and  plasters,  and  placing  the  patient  on  the  injured  side,  so 
that  this  may  be  most  dependent;  should  the  lips  of  the  wound  have 
already  become  adherent  to  one  another,  they  may  even  be  gently  and 
carefully  separated  b}^  the  introduction  of  a  probe,  and  in  this  way  an 
outlet  afforded  for  the  effused  matters. 

When  a  portion  of  intestine  or  of  omentum  has  protruded,  it  should 
be  replaced  as  speedily  as  possible,  before  strangulation  has  occurred, 
which  may  occasion  gangrene.  The  abdominal  muscles  should  be 
relaxed  by  bending  the  thigh  upon  the  abdomen,  when  the  Surgeon  may 
gradually  push  back  the  protrusion  by  steady  pressure  upon  it ;  he 
must  not,  however,  employ  any  force,  nor  any  rough  handling  of  the 
exposed  and  delicate  parts;  but  if  their  return  cannot  readil}’’  be  effected, 
owing  to  the  constriction  of  the  neck  of  the  tumor,  the  aperture  through 
which  they  have  escaped  must  be  carefully  enlarged  in  a  direction  up¬ 
wards,  by  means  of  a  probe-pointed  bistouiy,  or  a  hernia-knife  guided 
by  a  flat  director.  The  incision  necessary  to  enlarge  the  opening 
sufficiently  for  reduction,  need  not  exceed  half  an  inch  in  length.  In 
replacing  the  protruded  parts,  whether  by  the  aid  of  incision  or  not, 
care  must  be  taken  that  they  are  fairly  put  back  into  the  cavity  of  the 
abdomen,  and  not  pushed  up  into  the  sheath  of  the  rectus,  or  into  the 
subserous  areolar  tissue  lying  before  the  peritoneum;  an  accident  that 
would  be  fatal  by  allowing  the  constriction  of  the  neck  of  the  protrusion 
to  continue  unrelieved.  In  effecting  the  return,  the  Surgeon  should  not 
push  his  finger  into  the  abdomen,  but  must  content  himself  with  simply 
replacing  tlie  protruded  gut  or  omentum,  and  allowing  it  to  remain  in 
the  immediate  neio-hborhood  of  the  wound  in  the  abdominal  wall,  to 
which  it  will  contract  adhesions ;  and  through  wdiich  its  contents  may 
escape,  in  the  event  of  any  sloughing  being  set  up  in  it.  If  the  protru¬ 
sion  be  inflamed, it  must  equally  be  replaced  without  delay;  but,  should 
the  intestine  have  become  gangrenous  from  continued  constriction  and 
exposure,  no  attempt  at  reduction  should  be  made,  but  an  incision  must 
be  carried  through  it,  so  as  to  allow  the  escape  of  feces,  and  the  forma¬ 
tion  of  an  artificial  anus.  If  the  protruded  omentum  be  gangrenous,  it 
must  be  excised  on  a  level  with  the  peritoneum,  to  the  aperture  in  which 
that  portion  lying  within  the  abdomen  will  have  contracted  adhesions. 

If  the  intestine  that  protrudes  he  wounded.,  the  treatment  of  the  aper¬ 
ture  in  the  gut  will  call  for  special  attention;  and  Surgeons  have  been 
somewhat  divided  as  to  the  question  of  the  propriety  of  stitching  it 
up.  Scarpa  and  S.  Cooper  were  opposed  to  this  practice  on  the  ground 
that  it  does  not  prevent  extravasation,  and  that  the  stitches  produce 
irritation  by  acting  as  foreign  bodies.  They  proposed  to  return  the 
w'ounded  gut,  taking  care,  however,  to  leave  the  aperture  in  it  to 


TREATMENT  OF  WOUNDED  INTESTINE. 


555 


correspond  with  that  in  the  abdominal  wall,  so  that  an  artificial  anus 
might  be  established  by  the  cohesion  of  the  edges  of  the  openings  to  one 
another,  this  adhesion  preventing  extravasation.  To  this  practice  the 
great  objection  exists,  that  extravasation  will  probably  occur  before 
there  has  been  time  for  the  effusion  of  lymph,  and  the  agglutination  of 
the  contiguous  surfaces;  besides  which,  it  is  impossible  to  secure  the 
necessary  correspondence  between  the  two  apertures,  the  wounded  gut 
being  veiy  liable  to  alter  its  position  after  it  has  been  replaced.  It  has 
also  been  found  by  experience  that  one  of  the  objections  urged  against 
the  employment  of  a  suture,  that  it  cannot  prevent  the  escape  of  feculent 
matter,  is  not  valid.  If  it  be  properly  applied,  it  ma}^  effectually  do  so, 
as  was  shown  by  a  successful  case  under  my  care,  the  details  of  which 
were  published  in  the  Lancet  for  1851.  That  the  stitches  act  as  sources  of 
irritation  to  any  extent,  is  also  doubtful.  Travers  found  by  experiment 
that,  when  a  wounded  gut  was  sewn  up,  and  returned  into  the  abdomen, 
the  sutures  quickly  became  bridged  or  coated  over  with  a  thick  la3’er  of 
l^^mph,  and,  gradually  ulcerating  their  wa}’^  inwards,  at  last  dropped 
into  the  cavit}^  of  the  intestine,  being  discharged  per  anuin^  and  leaving 
a  firm  cicatrix  at  the  point  to  which  they  had  been  applied.  For  these 
various  reasons,  Guthrie,  Travers,  and  other  Surgeons  of  experience, 
advocate  the  practice  of  stitching  up  the  wound  in  a  protruding  intes¬ 
tine  in  suitable  cases,  with  which  opinion  I  entirel}'  agree.  It  is,  however, 
evident  that  no  positive  and  unvaiying  rule  can  be  laid  down  that  is 
applicable  to  all  cases.  Much  must  depend  on  the  nature,  cause,  and 
extent  of  the  wound  in  the  gut.  If  it  be  veiy  large  and  transverse,  the 
result  of  gunshot  violence  or  other  contusing  force,  no  suture  can  be  of 
an3"  service ;  for,  not  only  might  it  be  difficult  to  bring  the  edges  together, 
but  they  would  probably  not  cohere  to  one  another,  nor  to  the  abdominal 
wall.  If,  however,  the  wound  be  punctured  or  excised  and  of  moderate 
extent,  the  case  is  different.  Much  will  also  depend  upon  the  way  in 
which  the  sutures  are  applied.  They  should  be  introduced  by  means  of 
a  fine  round  needle,  armed  with  sewing  silk,  in  such  a  wa}^  that  the 
peritoneal  surfaces  on  each  side  of  the  wound  are  brought  into  contact : 
adhesion  takes  place  solely  between  these,  the  wound  in  the  other  struc¬ 
tures  of  the  gut  filling  up  b}’'  plastic  deposit.  It  has  been  recommended 
that  the  needle  should  penetrate  the  peritoneal  and  areolar  coats  onl3",  no 
muscular  tissue  being  taken  up  in  it,  lest  retraction  of  the  included  fibres, 
by  dragging  upon  the  stitches,  might  reopen  the  wound.  This  advice, 
however,  it  is  extremel3^  difficult  to  follow. 

The  safer  plan  is  doubtless  to  carry  the 
suture  through  the  whole  thickness  of  the 
gut,  bringing  the  stitches  out  at  about 
one-sixth  of  an  inch  from  the  edge  of 
the  cut,  in  such  a  way  that  the  serous 
surfaces  are  drawn  into  apposition.  The 
kind  of  suture  that  should  be  used  is  here 
represented  (Fig.  204).  When  the  lips  of 
the  wound  have  been  nearly  brought  into 
apposition  in  this  way,  it  has  been  pro¬ 
posed  to  leave  the  end  of  the  thread 
hanging  out  of  the  aperture  of  the  ab¬ 
dominal  w^all,  and  to  withdraw  it  when  it 
becomes  loose ;  but  I  think  it  better  not 
to  leave  it,  as  it  might  induce  great  irri¬ 
tation,  acting  like  a  seton  in  the  peritoneal 


Fig.  204. 


Applicatiou  of  Suture  to  Wounded 
Bowel. 


556 


INJURIES  OF  THE  ABDOMEN  AND  PELVIS. 


cavity.  The  ends,  therefore,  should  be  cut  short  close  to  the  knot,  when 
the  suture  will  eventually  become  covered  with  lymph,  and  find  its  way 
into  the  inside  of  the  gut  by  ulcerating  through  the  muscular  and 
mucous  coats. 

Should  the  aperture  in  it  admit  of  being  thus  closed,  the  protruded 
portion  of  the  intestine  must  be  reduced,  having  previously  been  properly 
cleansed  with  a  little  lukewarm  water.  Should,  however,  the  protruded 
gut  be  too  extensively  torn,  and  especially  if  it  be  lacerated  by  gunshot 
injury,  it  would  be  useless  to  stitch  it  up,  and  it  must  be  gently  and 
carefully  reduced.  The  reduction  must  be  effected  in  the  way  that  has 
been  already  described,  the  Surgeon  being  especially  careful  not  to  push 
the  wounded  coil  of  intestine  far  into  the  abdomen,  but  to  leave  it  close 
to  the  external  orifice,  so  that,  in  the  event  of  extravasation  occurring,  or 
the  stitches  giving  way,  a  ready  outlet  may  be  afforded.  Should  the 
w'ound  in  the  abdominal  wall  be  extensive,  it  must  be  closed  by  sutures 
and  plasters,  supported  by  a  bandage,  the  interior  angle  being  left  open 
to  allow  the  escape  of  extravasation.  Tfie  wound  in  the  peritoneum  had 
better  be  left ;  but  should  it  be  very  extensive,  recourse  might  be  had  to 
the  practice  that  was  successfully  adopted  in  such  circumstances  by 
Ward,  of  stitching  up  the  aperture  in  this  membrane. 

The  after-treatment  must  be  conducted  in  all  respects  on  the  same 
principles  as  in  the  case  of  an  intestine  wounded  without  protruding. 
Care  must  be  taken,  by  attention  to  the  position  of  the  patient,  and  by 
the  free  administration  of  opium,  to  keep  the  bowel  as  quiet  as  possible 
near  the  external  opening ;  the  urine  should  be  drawn  off  twice  in  the 
twenty-four  hours,  and  no  purgative  whatever  administered,  lest  by  the 
excitation  of  peristaltic  action  adhesion  be  disturbed,  and  extravasation 
take  place.  After  the  lapse  of  six  or  eight  days  an  enema  ma}^  be  thrown 
up,  and  repeated  from  time  to  time.  No  food  should  be  allowed  for  the 
first  three  days,  during  which  time  ice  and  barley-water  should  be  freely 
taken  ;  after  this,  beef-tea,  and  light  food  that  leaves  no  solid  residue, 
may  be  given.  It  is  of  great  importance  that  no  solid  food  should  be 
administered  for  at  least  two  or  three  weeks  after  the  occurrence  of  the 
injuiy.  In  a  case  of  wound  of  the  intestine  which  was  under  my  care,  the 
patient,  who  was  progressing  very  favorably,  and  eventually  recovered, 
nearly  lost  her  life  by  eating  the  pulp  of  an  orange  on  the  tenth  day. 

Traumatic  Peritonitis  is  the  great  danger  to  be  apprehended  in  all 
serious  injuries  of  the  abdomen,  and  it  is  by  inducing  this  that  extrava¬ 
sation  of  feces  or  of  blood  so  frequently  proves  fatal.  It  is  true  that  a 
certain  degree  of  inflammation  of  the  peritoneum  is  necessary  for  the 
healing  of  all  abdominal  wounds,  but  it  must  be  limited  in  extent  and 
plastic  in  character.  It  is  the  more  diffuse  form  of  peritonitis,  attended 
by  the  exudation  of  turbid  serum  and  shreddy  ill-conditioned  lymph, 
that  is  so  speedily  fatal.  In  these  cases,  we  meet  with  the  ordinaiy 
symptoms  of  the  idiopathic  form  of  this  affection ;  uniform  tenderness 
about  the  abdomen,  but  more  particularl3^  in  the  neighborhood  of  the 
injury,  with  occasional  stabbing  pains,  followed  by  tympanitic  distension, 
vomiting  and  hiccup,  a  small,  quick,  hard  pulse,  often  assuming  a  wiiy 
incompressible  character,  with  considerable  pyrexia,  and  great  anxiety 
of  countenance.  This  diffuse  traumatic  peritonitis  will  set  in  and  run 
its  course  with  great  rapidity.  In  a  case  in  University  College  Hospital, 
alread}^  alluded  to,  of  bullet-wound  of  the  abdomen,  the  patient  lived 
twentj’-four  hours.  Two  or  three  pints  of  serous  effusion  with  much 
puro-plastic  matter  were  found  ;  and  great  reddening  of  the  whole  of  the 
visceral  and  much  of  the  parietal  peritoneum  had  ensued.  In  another 


RUPTURE  OF  THE  BLADDER. 


557 


case  of  rupture  of  the  ileum,  the  consecutive  peritonitis  proved  fatal  in 
about  thirty  hours  after  the  accident.  This  extreme  rapidity  in  its  course 
and  fatal  termination,  distinguishes  traumatic  from  idiopathic  peritonitis. 
To  what  is  the  rapid  fatalit}^  of  traumatic  peritonitis  due  ?  It  is  not,  as 
in  the  case  of  traumatic  inflammations  of  the  head  and  chest,  by  the 
direct  interference  with  organs,  the  health}^  performance  of  whose  action 
is  directly  essential  to  the  continuance  of  life.  It  is  also  far  more  rapidly 
fatal  than  any  inflammation  of  the  pleura,  pericardium,  or  arachnoid. 
May  it  not  be  due  to  some  direct  impression  upon  the  S3^mpathetic 
ganglia — to  the  collapse  of  nervous  shock,  associated  with  and  intensified 
by  an  acute  contiguous  inflammation.  In  some  cases  the  disease  assumes 
a  more  chronic  form  ;  and  recovery  occasionally  takes  place.  In  these 
less  acute  forms  of  the  disease,  where  life  is  prolonged  for  many  days  or 
several  weeks,  effusion  of  dark  or  turbid  serous  fluid  takes  place  in  the 
peritoneal  cavity.  As  this  effusion  increases,  dulness  on  percussion  will 
manifest  itself — usually  first  on  the  flanks,  and  then  gradual!}'  extending 
forward  until  it  may  occupy  a  great  extent  of  surface  in  the  abdomen. 

In  the  Treatment  of  this  disease,  we  must  be  guided  by  the  character 
of  the  inflammation.  If  it  be  sthenic,  and  the  patient  young  and  robust, 
he  maybe  bled  in  the  arm,  but  should  certainly  have  leeches  abundantly 
applied  over  the  surface  of  the  abdomen  ;  a  pill,  composed  of  two  grains 
of  calomel  and  one  grain  of  opium,  may  then  be  administered  every 
sixth  hour,  or  oftener  if  the  j^atient  be  not  influenced  by  the  narcotic  ; 
and  rigid  abstinence  from  food  should  be  enforced,  ice  and  barley-water 
alone  being  allowed.  If  the  peritonitis  be  the  result  of  a  wounded  intes¬ 
tine,  it  is  safer  to  omit  the  calomel,  using  instead  mercurials  to  the  inside 
of  the  thighs,  but  giving  opium  freely.  When  the  peritonitis  occurs  in 
an  old  or  feeble  subject,  our  principal  trust  must  be  in  the  administration 
of  opium  and  in  free  leeching  of  the  abdomen,  followed  perhaps  by 
blister,  which  may  be  dressed  with  mercurial  ointment.  In  these  cases, 
however,  early  support  wdll  be  required,  with  perhaps  the  administration 
of  wine  or  stimulants.  The  inflammatory  extravasation  will  gradually 
be  absorbed  under  the  influence  of  the  calomel,  aided  by  blisters. 

INJURIES  OF  THE  PELVIC  VISCERA. 

Bladder. — Rupture  of  the  Bladder^  from  blows  upon  the  abdomen, 
is  not  of  very  unfrequent  occurrence.  It  can  scarcely  happen  when  the 
organ  is  empty,  as  it  then  sinks  down  under  cover  of  the  pelvic  bones. 
But  when  tlie  bladder  is  greatly  distended,  rising  high  above  the  pubes, 
and  thinned  proportionately  to  its  distension,  it  may  very  readily  be 
ruptured,  even  by  very  slight  degrees  of  external  violence,  as  by  one 
man  rolling  over  another  in  a  drunken  scuffle,  or  by  a  person  running 
against  a  post,  or  falling  out  of  bed. 

The  Effects  of  this  injury  vary  considerably,  according  to  the  part 
that  has  given  way  or  been  wounded.  If  the  laceration  have  occurred  in 
those  portions  of  the  viscus  that  are  invested  by  peritoneum,  the  urine 
will  at  once  escape  into  the  pelvic  and  abdominal  cavities,  and  speedily 
occasion  death  by  intense  irritation  and  inflammation.  I  have,  however, 
seen  a  case  in  wfflich,  even  in  these  circumstances,  the  patient  survived 
ten  days.  If,  on  the  other  hand,  that  portion  of  the  organ  have  been 
ruptured  which  is  uncovered  by  the  peritoneum,  the  urine  may  infiltrate 
into  the  areolar  tissue  between  the  membrane  and  the  abdominal  wall, 
and,  diffusing  itself  widely,  produce  destructive  sloughing  of  the  tissues 
amongst  which  it  spreads.  In  these  cases  life  may  be  prolonged  for 


558 


IXJUEIES  OF  THE  ABDOMEN  AND  PELVIS. 


some  clan’s,  when  the  patient  commonly’  sinks  from  the  combined  irrita¬ 
tion  and  inflammation.  An  open  wound  of  the  bladder  is  b}^  no  means 
so  dangerous  as  its  subcutaneous  rupture.  Many  patients  have  recovered 
whose  bladders  have  been  perforated  and  traversed  by  bullets,  the 
urine  finding  a  free  exit  through  the  apertures,  and  consequently  not 
tending  to  extravasate  itself.  Guthrie  relates  several  cases  of  this  kind; 
and  Thomson  saw  fourteen  cases  after  the  battle  of  Waterloo,  in  a  fair 
way  of  recovery.  Thus,  although  we  ma}’  look  upon  this  accident  as  of 
the  gravest  character,  3’et  it  cannot  be  considered  as  being  necessarily 
fatal. 

Symptoms. — The  injuiy  in  the  In'pogastric  region,  followed  b}-  col¬ 
lapse,  b}'  intense  burning  pain  in  the  abdomen  and  pelvis,  with  inability 
to  pass  the  urine,  or,  if  any  have  escaped  from  the  urethra,  its  being 
tinged  with  blood,  are  usuall}'  sufficient  to  point  to  the  nature  of  the 
accident.  If,  in  addition,  it  be  found  on  introducing  a  catheter  that  the 
bladder  is  empty,  or  that  but  a  small  quantity  of  bloody  urine  escapes, 
the  Surgeon  ma}’  be  sure  that  this  organ  has  been  burst.  In  the  case  of 
gunshot  injuiy  the  escape  of  urine  which  generalh^  takes  place  through 
the  track  of  the  bullet  will  afi’ord  incontestable  evidence  of  the  mischief 
that  has  been  produced. 

In  the  Treatment.,  the  most  important  indication  is  the  prevention  of 
further  extravasation  by  the  introduction  of  a  full-sized  elastic  catheter 
into  the  bladder.  This  must  be  tied  in,  and  should  be  left  open,  or  with 
a  vulcanized  India-rubber  tube  attached,  so  that  the  urine  may  dribble 
away  through  it  as  fast  as  it  accumulates.  If  aiy  sign  of  extravasation 
appear  externall}^,  free  and  deep  incisions  should  be  made  into  the  part, 
so  as  to  facilitate  the  early  escape  of  the  effused  fluid  and  the  putrid 
sloughs.  I  cannot  but  consider  all  active  anti-inflammatory  treatment 
as  out  of  place  in  these  injuries,  never  having  seen  the  slightest  benefit 
follow  its  emploj’ment.  The  onl}"  chance  that  the  patient  has,  if  once 
extensive  extravasation  have  occurred,  is  that  there  ma}"  be  sufficient 
power  left  in  the  constitution  to  throw  out  a  barrier  of  13’mph  that  will 
limit  the  diffuse  and  sloughing  inflammatoiy  action  set  up  ;  and  the 
prospect  of  this  would  certainly  not  be  increased  b}"  the  employment  of 
depletoiy  measures.  There  will  also  be  so  great  a  call  upon  the  powers 
of  the  s^’stem  at  a  later  period,  after  sloughing  has  fairl}’  set  in,  that 
a  supporting  or  even  a  stimulating  plan  of  treatment  will  rather  be 
required. 

Foreign  Bodies^  such  as  pieces  of  catheters,  tobacco-pipes,  pencils, 
etc.,  are  occasional!}’  met  with  in  the  urinaiy  organs,  having  been  intro¬ 
duced  through  the  urethra.  In  some  cases  they  are  soon  spontaneously 
expelled,  but  more  usuall}"  the}' require  extraction;  sometimes  they  may 
be  fortunately  seized  with  a  small  lithotrite  or  urethral  forceps  in  the 
direction  of  their  long  axis,  and  thus  extracted ;  but  more  frequently 
they  require  to  be  removed  through  an  incision  made  into  the  bladder. 
This  is  more  safely  done  by  the  median  than  by  the  lateral  operation 
of  cystotomy. 

Musket-balls,  pieces  of  clothing,  etc.,  are  occasionally  lodged  in  the 
bladder  in  gunshot  wounds  of  that  organ.  These  speedily  become  in- 
crusted  with  urinary  deposits,  and,  giving  rise  to  the  symptoms  of  stone 
in  the  bladder,  require  to  be  removed  by  cystotomy,  an  operation  that 
has  proved  very  successful  in  these  cases,  evidently  in  consequence  of 
the  healthy  condition  of  the  urinary  organs.  Dixon  has  collected  from 
various  works  the  details  of  fifteen  cases,  in  which  balls,  that  had  either 
primarily  entered  the  bladder,  or  had  found  their  way  into  this  organ 


WOUNDS  OF  THE  UKETHRA. 


559 


by  abscess  or  ulceration  after  having  been  lodged  in  the  neighborhood, 
were  extracted  b}^  operation.  In  ten  of  these  cases  the  result  was  suc¬ 
cessful  ;  in  the  remaining  five  no  record  is  made  of  the  termination. 

Rupture  of  the  Ureter. — Stanle}'"  has  related  a  remarkable  case  in 
which  the  Ureter  was  ruptured  b3^  external  violence,  and  in  which  the 
patient  recovered  ;  a  very  large  accumulation  of  fluid  forming  on  the 
injured  side  of  the  abdomen,  with  considerable  circumscribed  tumefaction 
and  fluctuation,  and  which  required  repeated  tapping.  In  another  case, 
in  which  the  PelviB  of  the  Kidney  was  ruptured,  a  similar  collection  of 
urine  took  place  within  the  abdomen,  requiring  tapping;  as  much  as  six 
pints  being  removed  at  one  sitting.  On  examination  after  death,  wdiich 
occurred  in  the  tenth  week  from  the  accident,  a  large  cyst  was  found 
behind  the  peritoneum,  communicating  with  the  pelvis  of  the  kidne3^ 

Wounds  of  the  Organs  of  Generation  in  the  male  may  be  acci¬ 
dental,  occasioned  b}^  sharp  instruments  or  gunshot,  or  ma}^  be  self- 
inflicted.  When  only  involving  the  integuments,  they  present  nothing 
peculiar  or  differing  from  similar  wounds  in  other  situations,  except  in 
the  great  reparative  power  that  the  scrotal  or  penile  coverings  possess. 
Even  when  the  whole  of  the  skin  of  the  part  has  been  cut  or  torn  away, 
the  organ  will  speedily"  recover  itself.  In  one  curious  case  under  my 
care,  in  which  a  woman  had  unsuccessfull}^  attempted  to  cut  off  a  man^s 
penis  with  a  carving-knife,  the  organ,  wEich  had  had  the  whole  of  its 
integuments  torn  off  from  the  root  forwards,  quickl}’  covered  itself  with 
a  new  integument,  wdiich  speedil^^  assumed  the  soft  and  supple  character 
natural  to  the  skin  of  these  parts. 

When  the  organ  is  more  deepl}'  w'ounded,  there  are  two  special  sources 
of  danger,  viz.,  hemorrhage,  and  wound  of  the  urethra.  The  hemor¬ 
rhage  is  usually"  very  profuse.  If  it  proceed  from  a  distinct  arterial 
trunk,  such  as  the  dorsal  artery  or  that  of  the  corpus  cavernosum,  the 
vessel  must  be  ligatured.  If  it  occur  from  general  oozing  from  the  vas- 
cular  tissue  of  the  penis,  it  may  be  arrested  b}’-  cold,  pressure,  or  astrin¬ 
gents.  Pressure  is  best  applied  by  passing  a  large  catheter  into  the 
bladder,  and  then  compressing  the  organ  against  this  b^"  means  of  a 
narrow  bandage  or  circular  strip  of  plaster. 

Injuiy  of  the  genital  organs  by  self-mutilation  in  cases  of  sexual 
mania  or  melancholia  is  occasionally^  met  wdth.  In  some  instances  the 
patient  has  cut  off  one  testis  ;  in  others,  the  penis  ;  in  others,  again,  the 
wdiole  of  the  sexual  organs.  Injuries  such  as  these  present  no  very 
special  character,  and  require  to  be  treated  on  ordinary  principles,  the 
great  point  being  of  course  the  restraint  of  hemorrhage. 

Urethra. —  Wound  of  the  Urethra  b}^  gunshot  injury,  or  sharp  instru¬ 
ments,  is  a  troublesome  accident,  on  account  of  the  liability  to  urinary 
infiltration  and  ultimately^ to  fistula.  It  maybe  recognized  by  the  escape 
of  blood  from  the  meatus,  and  of  urine  from  the  w'ound.  The  Treatment 
consists  in  the  introduction  of  a  gum  catheter,  which  should  be  tied  in  ; 
and  if  the  edges  of  the  wound  be  clean  cut,  they  may  be  brought  together 
by  interrupted  sutures. 

Laceration  of  the  Urethra  is  immediately^  attended  by^  most  serious 
syunptoms,  and  remotely  followed  by^  most  disastrous  consequences.  It 
very  frequently  occurs  in  men  employed  in  building,  from  slipping  in 
walking  across  an  unfinished  floor,  in  such  a  way^  as  to  fall  heavily 
astride  upon  one  of  the  joists,  thus  bruising  the  perinseum  and  rupturing 
the  urethra  and  other  structures  lying  under  the  rami  and  sy^mphysis  of 
the  os  pubis.  The  same  accident  may’"  arise  in  other  w^ay’-s.  Thus  I 
have  met  with  in  it  a  farrier,  kicked  in  the  perinseum  whilst  shoeing  a 


560 


INJURIES  OF  THE  ABDOHEN  AND  PELVIS. 


horse ;  and  it  has  been  met  Avith  as  a  consequence  of  laceration  by  a 
splinter  of  bone  from  a  fracture  of  the  ramus  of  the  os  pubis. 

In  these  injuries  the  integuments  are  usually  untorn,  but  deeply  ecchy- 
mosed.  The  extravasation  of  blood  is  often  considerable,  extending 
into  the  scrotum,  which  rapidly  swells  up  and  becomes  black.  It  ma}", 
indeed,  be  very  serious,  arising  in  some  cases  from  the  lacerated  struc¬ 
tures  and  the  torn  superficial  or  transverse  arteries  of  the  perinseum;  in 
other  instances  from  the  corpus  spongiosum,  the  bulb,  or  the  artery  of 
the  bulb.  In  all  cases  of  lacerated  urethra,  blood  will  drip  from  the 
orifice  ;  and  if  the  bulb  and  its  arteries  have  been  torn,  the  hemorrhage 
from  this  may  be  veiy  great,  a  pint  or  more  of  blood  being  thus  rapidly 
lost,  in  addition  to  great  accumulations  in  the  perinaeum  and  scrotum, 
distending  these  parts  with  coagula  and  infiltration. 

In  consequence  of  the  loss  of  the  continuity  of  the  canal  and  the  com¬ 
pression  or  plugging  of  the  torn  part  by  the  coagula  of  the  extravasated 
blood,  the  urine  cannot  be  passed  and  the  bladder  graduall}-  fills.  If  the 
patient  attempt  to  empt}^  it,  only  a  few  drops  will  issue  from  the  urethral 
orifice  ;  but  he  will  be  seized  with  severe  burning,  smarting  pain  in  the 
perinaeum,  and  the  ultimate  evils  of  the  injury  will  be  greatly  aggravated, 
for,  wherever  the  urine  penetrates,  sloughing  of  areolar  tissue  will  inva- 
riabl}’  and  rapidly  ensue.  There  is  this  great  difference  between  extra- 
A^asation  of  urine  from  ruptured  bladder  and  from  lacerated  urethra :  in 
the  first  case  the  urine  escapes  involuntaril}^  from  the  injured  organ ;  in 
the  second  instance,  no  urine  will  escape  from  the  torn  urethra,  unless 
b}'  a  voluntaiy  expulsive  efi'ort  on  the  part  of  the  patient.  The  suflerings 
of  the  patient  speedily  become  aggravated  b}"  the  retention  of  the  urine 
and  the  distress  occasioned  by  the  distended  bladder;  and  the  necessity 
for  relief  thus  becomes  urgent,  lest  b}"  an  involuntary  spasmodic  effort 
the  urine  be  pumped  widely  into  the  already  broken  down  areolar  tissue 
of  the  perinceum  and  scrotum. 

The  ultimate  consequences  of  a  lacerated  urethra  are  no  less  serious 
than  the  immediate  effects.  If  the  floor  only  of  the  urethra  have  been 
lacerated,  leading  the  upper  part  of  the  wall  of  the  canal  intact,  the  con¬ 
tinuity  of  the  urethra  will  not  be  lost,  but  a  joermanent  traumatic  stric¬ 
ture  of  the  worst  kind  will  result.  If  the  urethra  have  been  completely 
torn  across,  or  slough  as  a  consequence  of  the  injurjq  obliteration  of  a 
portion  of  the  canal  may  ensue,  and  incurable  urinary  fistula  will  be  left 
in  the  perinmum. 

The  Treatment  consists  in  the  early  introduction  of  a  catheter  into 
the  bladder.  If  this  can  be  done  before  the  patient  has  made  an  attempt 
at  passing  his  urine,  much  of  the  immediate  danger  of  the  case  may  be 
averted  by  the  prevention  of  urinary  infiltration.  The  catheter,  which 
should  be  an  elastic  one,  must  be  left  in  the  bladder  for  a  few  days.  It 
should  not  be  plugged,  but  should  have  a  vulcanized  India-rubber  tube 
attached  for  the  urine  to  escape  as  fast  as  secreted.  If  anj’  hardness, 
throbbing,  or  other  sign  of  irritation  occur  in  the  perinmum,  free  incision 
should  be  made  into  the  part,  so  as  to  aiford  a  ready  outlet  for  any  urine 
that  may  have  been  effused.  If  the  Surgeon  find  it  impossible  to  intro¬ 
duce  a  catheter  into  the  bladder,  the  urethra  being  torn  completely  across, 
he  should  pass  it  as  far  as  it  will  go,  and  then,  putting  the  patient  in  the 
position  for  lithotom}',  make  a  free  incision  in  the  mesial  line  upon  the 
point  of  the  instrument,  so  as  to  make  an  opening  in  the  peringeum  com¬ 
municating  with  the  deeper  portion  of  the  urethra ;  any  arteries  that 
bleed  freely"  should  be  tied.  He  must  then  endeaA^or  to  pass  the  catheter 
into  the  bladder,  through  the  proximal  portion  of  the  injured  urethra. 


LACERATION  OF  THE  PERINH^UM. 


561 


This  is  often  extremelj^  difficult.  If  the  floor  of  the  urethra  only  have 
been  torn,  it  may  be  accomplished  by  keeping  the  point  of  the  catheter 
well  against  the  upper  wall  of  the  canal ;  but  if  the  urethra  have  been 
completely  torn  across,  it  will  tax  all  the  skill  of  the  Surgeon  to  direct 
and  pass  the  instrument  into  the  vesical  end  of  the  canal.  An  ingenious 
plan  for  overcoming  the  difficulty  in  such  cases  was  suggested  by  T.  P. 
Teale  (senior),  of  Leeds.  A  director  is  first  introduced  into  the  vesical 
end  of  the  opening  in  the  urethra,  and  over  it  a  dilator  is  passed ;  the 
director  being  then  withdrawn,  the  catheter  is  readily  introduced  through 
the  dilator.  Should  the  urine  become  extravasated,  the  Surgeon  must 
follow  its  course  with  free  and  deep  incisions,  supporting  the  strength  of 
the  patient  at  the  same  time  by  a  due  allowance  of  stimulants  and 
nourishment.  If,  when  the  urethra  is  completely  torn  across,  a  catheter 
cannot  be  passed,  and  the  urine  finds  a  difficulty  in  escaping,  relief  not 
being  afforded  by  the  perinaeal  incision,  and  the  bladder  becoming  over¬ 
distended,  this  organ  should  be  tapped  through  the  rectum,  in  the  wa}^ 
that  will  be  described  when  we  come  to  speak  of  diseases  of  the  urinary 
organs.  But  tapping  through  the  rectum  should  not  be  done  before  the 
perinagal  incision  is  made. 

Vagina  and  Rectum. — Foreign  Bodies  are  occasionally  thrust  forci¬ 
bly  into  or  impacted  in  the  vagina  or  rectum.  When  a  foreign  body,  such 
as  a  stick,  or  a  broom-handle,  or  the  leg  of  a  chair,  is  thrust  forcibl}"  up 
the  rectum  by  a  person  falling  on  such  a  thing,  two  dangers  may  result ; 
either  extensive  laceration  of  the  sphincter  and  perinseum,  with  hemor¬ 
rhage  ;  or  transfixion  of  the  gut  and  wound  of  the  peritoneum,  with  con¬ 
secutive  inflammation  of  that  membrane.  The  consequences  of  such  an 
injury  present  nothing  very  special,  and  require  to  be  treated  on  ordinary 
principles.  If  in  the  fall  the  foreign  body  have  been  forcibly  thrust  into 
the  vagina,  there  will  be  danger  of  injury  to  the  bladder  or  peritoneum  ; 
but  the  chief  danger  will  result  from  laceration  of  the  labium,  and  free 
hemorrhage  from  this  source.  I  have  several  times  seen  enormous  quan¬ 
tities  of  blood  thus  lost.  This  hemorrhage  is  best  arrested  by  plugging 
firml}^  with  lint  soaked  in  a  solution  of  the  perchloride  of  iron,  and  the 
pressure  of  a  bandage. 

A  variet}’^  of  things,  such  as  pieces  of  stick,  glass  bottles,  gallipots, 
etc.,  have  been  introduced  and  impacted  in  these  canals.  Their  extraction 
is  often  very  difficult,  in  consequence  of  the  swelling  of  the  mucous  mem¬ 
brane  over  and  around  them,  and  the  depth  to  which  the}^  have  been 
pushed.  In  order  to  remove  them,  the  use  of  lithotomy  or  necrosis 
forceps  may  be  required.  In  some  cases  the  foreign  body  will  occasion 
ulceration  into  the  bladder ;  and  it  has  been  found  to  transfix  the  wall 
of  the  canal  in  which  it  is  lodged,  and,  b}’"  penetrating  the  peritoneum, 
has  speedily  occasioned  the  patient’s  death.  A  remaBcable  case  of  this 
kind  occurred  in  my  practice,  in  which  a  cedar  pencil,  five  inches  long, 
and  cut  to  a  point,  had  been  forced  up  by  the  patient  herself,  a  young 
woman,  through  the  posterior  wall  of  the  vagina  into  the  abdominal 
cavit}^  Here  it  transfixed  two  coils  of  the  small  intestine,  and,  after  a 
sojourn  of  eight  months,  I  extracted  it  by  an  incision  through  the  anterior 
abdominal  wall,  midway  between  the  umbilicus  and  Poupart’s  ligament, 
where  its  point  was  engaged  in  the  fascia  transversalis.  It  had  occa¬ 
sioned  repeated  attacks  of  peritonitis;  and,  after  its  extraction,  death 
resulted  from  that  cause. 

Laceration  of  the  Perinaeum. — The  perinseum  is  occasionally  rup¬ 
tured  during  parturition.  The  extent  of  the  laceration  varies  greatly, 
and  influences  materially  the  ultimate  issue  of  the  case.  In  some  cases 
YOL.  I _ 36 


562 


INJURIES  OF  THE  ARUOMEN  AND  PELVIS. 


there  is  merely  a  slight  rent  at  tlie  fourchette ;  in  others,  the  whole  peri- 
nmum  has  given  way  as  far  as  the  sphincter  ani ;  in  a  third  class  the 
sphincter  is  torn  as  well ;  and  in  a  fourth  the  rent  has  extended  into  the 
recto-vaginal  septum.  The  worst  cases  are  those  in  which  the  perinaeum 
has  been  torn,  and  the  recto-vaginal  septum  destroyed  by  sloughing  from 
prolonged  impaction  of  the  foetal  head.  In  such  cases  the  loss  of  soft 
tissues  and  the  existence  of  dense  cicatricial  bands  render  complete  union 
by  operation  very  problematical. 

The  length  of  time  that  has  elapsed  since  the  occurrence  of  the  injury 
is  of  little  consequence.  It  is  as  easy  to  repair  a  perinaeum  that  has  been 
lacerated  for  ten  years,  as  for  ten  da3^s.  A  very  serions  evil  arising  from 
ruptured  perinaeum  is  the  loss  of  support  to  the  pelvic  viscera,  and  the 
consequent  liability  to  prolapsus  of  the  uterus  or  of  the  vaginal  wall. 
When  the  sphincter  or  the  recto-vaginal  septum  has  given  way,  inconti¬ 
nence  of  feces  to  a  greater  or  lesser  extent  is  the  consequence,  feculent 
matter  coming  away  in  a  fluid  state  involuntarily.  The  neighboring  parts 
are  from  this  cause  liable  to  excoriation  ;  and  not  unfrequently  the  rectal 
mucous  membrane  becomes  prolapsed  or  hsemorrhoidal. 

The  Treatment,  which  is  purely  operative,  consists  of  a  plastic  pro¬ 
cedure,  having  for  its  object  the  bringing  together  and  the  union  by  adhe¬ 
sion  of  the  opposite  sides  of  the  rent.  The  extent  and  difficulty  of  this 
operation  will  vary  according  to  the  extent  of  the  laceration,  and  its  pros¬ 
pect  of  success  will  depend  on  attention  to  several  points  in  its  perform¬ 
ance;  but  also,  as  is  the  case  with  most  plastic  procedures,  on  the  state 
of  the  patient’s  health.  This  should  be  brought  up  to  the  best  standard 
before  the  Surgeon  proceeds  to  operate.  All  local  irritations  should  be 
removed,  piles  or  prolapsus  ani  cured,  and  the  parts  brought  into  as 
health^^  a  state  as  possible. 

When  the  laceration  is  of  very  limited  extent  and  recent,  union  may 
usually  be  effected  by  the  introduction  of  a  point  or  two  of  suture,  and 
bringing  and  keeping  the  thighs  together.  Should  the  laceration,  though 
it  involves  the  whole  perinceum,  be  confined  to  this,  and  not  extend  into 
the  sphincter  ani,  it  may  usually  readily  be  repaired  by  paring  the  edges 
freely,  and  passing  two  deep  quilled  and  four  superficial  sutures,  so  as  to 
bring  the  opposite  sides  together,  as  will  immediately  be  described. 
After  the  operation,  the  patient  should  lie  on  her  side,  and  either  have 
the  urine  drawn  off  three  times  a  day,  or  wear  an  elastic  catheter  for  at 
least  a  week.  In  these  cases,  the  bowels  may  be  allowed  to  act  naturally, 
care  being  taken  that  the  motions  be  kept  awa^'  from  the  perinaeum,  which 
must  be  supported  by  the  nurse  when  the  bowels  act. 

AVhen  the  laceration  is  very  extensive,  extending  through  the  peri- 
noeum,  the  sphincter  ani,  and  the  posterior  wall  of  the  vagina  into  the 
rectum — in  fact,  tearing  through  the  recto-vaginal  septum — more  exten¬ 
sive  and  most  careful  treatment  will  be  required.  The  following  is  the 
mode  of  performing  the  necessary  operation. 

Operation  for  Rupture  of  the  Perinseum  involving  the  Recto-Vaginal 
Septum. — The  bowels  having  been  well  cleared  out,  the  patient  should  be 
placed  in  the  position  for  lithotomy.  The  upper  wall  of  the  vagina  being 
held  out  of  the  way  by  means  of  a  duck-billed  speculum,  the  edges  and 
sides  of  the  rent  must  be  freel}^  and  deeplj^  pared  in  a  horse-shoe  shape, 
so  as  to  leave  a  raw  surface  about  an  inch  in  width.  The  greatest  care 
must  be  taken  to  remove  every  particle  of  mucous  membrane  and  integu- 
mental  structure,  not  onlj"  from  the  sides  of  the  fissure,  but  also  from 
above  the  upper  angle  of  it,  in  the  recto-vaginal  septum,  and  from  the 
anterior  part  of  this.  Any  portion  of  these  structures  that  may  be  left 


TREATMENT  OF  LACERATED  PERINEUM. 


563 


Fig.  205. 


behind,  however  minute,  is  of  course  an  obstacle  to  union,  and  will  either 
interfere  complete^’’  with  it,  or  leave  a  fistulous  opening  in  its  site.  The 
sphincter  ani  should  then  be  freel}’’  divided  on  each  side  of  the  cocc3'x, 
as  recommended  b}^  Brown,  in  order  that  its  action  maj*  be  parah^zed, 
and  all  tension  of  the  part  removed ;  or,  what  is  better,  the  muscles 
around  the  aniis  may  be  loosened  by  subcutaneous  section  of  their  coc- 
C3’geal  attachments.  Three  points  of  quilled  suture  (Fig.  205)  should 
then  be  passed  deeply"  through  the 
freshened  sides  of  the  laceration, 
and  the  edges  brought  together  by 
a  few  points  of  interrupted  suture. 

The  deep  sutures  are  best  intro¬ 
duced  b}^  long  ngevus-needles.  The 
one  nearest  the  anus  should  be 
passed  first ;  and  if  the  recto-vagi¬ 
nal  septum  be  in^^olved  iu  the  rent, 
it  must  be  dipped  into  but  not 
passed  through  the  freshened  sur¬ 
face  of  this  part,  so  as  to  draw  it 
well  forwards  and  against  the  new 
perinseum.  .  The  sutures  should  be 
introduced  at  a  distance  of  one 
inch  from  the  cut  edge,  should 

pass  about  three-quarters  of  an  inch  in  depth,  and  be  brought  out  on  the 
other  side  at  the  same  distance  from  the  freshened  surfaces  as  that  at 
which  the}^  entered.  The  great  difficult}’’  in  this  operation  will  be  found 
to  consist  in  the  enlargement  of  the  aperture  in  the  recto-vaginal  septum, 
and  in  bringing  its  edges  together.  In  proportion  to  the  loss  of  sub¬ 
stance  that  has  occurred,  this  difficult}'  will  increase.  Sometimes  a  nar¬ 
row  band,  the  result  of  some  previous  ineffectual  attempt  at  union,  will 
be  found  to  stretch  across  the  gap  at  the  verge  of  the  anus.  This  should 
not  be  retained,  as  it  will  be  greatly  in  the  way  of  the  operator,  and  use¬ 
less  as  far  as  after-union  is  concerned. 

The  best  material  for  the  deep  sutures  is  strong  whip-cord  well  waxed, 
or  iron  wire.  I  now  generally  prefer  the  wire  as  less  irritating.  For 
the  superficial  sutures,  thin  annealed  silver  wire  should  be  applied  in  the 
continuous  manner  by  means  of  the  glover’s  stitch ;  the  parts  are  thus 
much  more  securely  and  easily  held  together  than  by  the  interrupted 
suture. 

The  success  of  the  operation  will,  to  a  great  extent,  depend  on  the 
attention  bestowed  on  the  after-treatment^  the  mode  of  conducting  which 
has  been  laid  down  with  much  precision  by  Brown.  The  principal  points 
to  be  attended  to  are  as  follows.  Immediately  after  the  operation,  a  full 
dose  of  opium  should  be  given,  and  followed  by  a  grain  once  or  twice  a 
day,  SQ  as  to  arrest  all  intestinal  action.  The  patient  should  be  laid  on 
her  side,  and  a  catheter,  furnished  with  a  long  India-rubber  tube,  retained 
so  as  to  prevent  any  dribbling  of  urine  over  the  raw  edges,  which  would 
be  fatal  to  their  union.  The  hemorrhage  usually  ceases  when  the  edges 
are  brought  together.  If  it  should  continue,  the  application  of  a  pad 
and  T -bandage,  and  of  ice  in  the  vagina,  will  generally  easily  control  it. 
The  deep  sutures,  if  of  whip-cord,  should  be  left  in  for  three  days,  as  a 
general  rule.  In  some  cases  they  may  even  be  retained  for  ninety-six 
hours ;  but  if  any  suppuration  be  set  up  along  their  track,  they  must  at 
once  be  withdrawn ;  if  of  wire,  they  may  be  left  longer — for  six  days. 
The  superficial  sutures  should  be  left  in  as  long  as  they  produce  no 


564  INJURIES  OF  THE  ABDOMEN  AND  PELVIS. 

irritation ;  when  of  silver  wire,  they  be  left  undisturbed  for  eight 
or  ten  days.  During  this  period,  I  have  found  it  advantageous  to  keep 
the  part  covered  with  collodion.  When  the  sutures  are  removed,  a  pad 
of  dry  lint,  supported  by  a  T -bandage,  should  be  applied.  When  the 
recto-vaginal  septum  has  been  implicated,  the  bowels  should  not  be 
allowed  to  act  for  at  least  ten  or  twelve  days,  lest  the  freshly  united 
surfaces  be  torn  through.  When  the  perinseum  only  has  been  the  seat 
of  laceration,  they  may  be  allowed  to  act  earlier.  During  the  whole  of 
the  treatment,  the  patient’s  strength  must  be  supported  by  abundant 
nourishment,  and  scrupulous  attention  paid  to  the  cleanliness  of  the 
parts,  which  should  be  frequently  syringed  with  carbolized  water  and 
covered  with  finely  carded  dry  wool. 

Plastic  operations  of  this  kind  should  not  be  performed  unless  the 
patient  be  in  a  good  state  of  health,  that  there  may  be  a  good  prospect 
of  immediate  union.  The  success  of  the  case  will  at  last  mainl}’-  depend 
on  the  extent  of  laceration,  or  rather  of  loss  of  substance,  in  the  recto¬ 
vaginal  septum.  If  this  be  uninjured,  or  merely  notched  as  it  were, 
there  will  be  but  little  difficulty  experienced  in  effecting  a  cure.  If,  on 
the  other  hand,  this  wall  be  deeply  lacerated,  or,  still  worse,  if  a  portion 
of  it  have  sloughed  away,  the  greatest  difficulty  may  result  in  effecting 
union ;  and  in  such  untoward  circumstances  it  may  happen,  that  the 
perinseum  unites,  but  that  a  fistulous  opening  is  still  left  in  the  recto¬ 
vaginal  wall,  requiring  a  future  plastic  operation  for  its  closure  {vide 
Chapter  LXYI.). 


DIVISION  THIKD. 

SURGICAL  DISEASES. 


DISEASES  AFFECTING  THE  TISSUES  GENERALLY. 


CHAPTER  XXX. 

MORTIFICATION,  OR  GANGRENE. 

The  death  of  a  part  of  the  bod}",  in  surgical  language,  is  termed  Morti¬ 
fication  or  Gangrene.  When  the  morbid  action  is  confined  to  the  osseous 
structures  or  to  the  cartilages,  it  is  termed  Necrosis;  when  limited  to 
the  soft  tissues  of  a  limb.  Sphacelus ;  and  when  accompanied  by  ulcera¬ 
tion,  it  is  called  Slough.  Many  other  varieties  of  gangrene  are  recognized 
by  Surgeons.  Like  all  other  diseases,  it  may  be  Acute  or  Chronic  in  its 
duration ;  as  the  parts  affected  are  moist  or  swollen,  or  dry  and  shrivelled, 
it  may  be  divided  into  the  Moist  and  the  Dry  or  Mummified  gangrene  ;  so 
again,  according  to  its  cause,  it  is  spoken  of  as  Idiopathic  or  Traumatic  ; 
and  very  frequently,  and  most  correctly  perhaps,  it  is  arranged  under 
the  denominations  of  Constitutional  and  Local.  Besides  these,  various 
Specific  forms  of  the  disease  are  met  with,  which  will  reciuire  special 
consideration. 

Local  Signs. — Whatever  form  the  gangrene  may  assume,  certain  local 
phenomena  are  common  to  all  varieties.  The  part  becomes  colder  than 
natural ;  not  only  is  it  colder  than  the  corresponding  part  on  the  opposite 
side  of  the  body,  but  the  temperature  may  fall  below  that  of  surrounding 
media.  The  sensibility  of  the  part  is  lost.  It  may  be  touched,  pricked, 
or  cut  without  feeling.  In  some  cases  the  sensibility  is  greatly  increased 
just  before  gangrene  sets  in,  intense  agonizing  pain  of  a  burning  or 
neuralgic  character  being  experienced,  wliich  soon  gives  way  to  complete 
insensibility.  All  motion  of  the  part  itself  ceases.  It  may  be  moved 
by  muscles  from  a  distance,  as  a  mortified  toe  might  be  moved  by  the 
unaffected  flexors  or  extensors,  but  it  has  no  power  of  motion  inde¬ 
pendently  of  that  which  is  communicated  from  a  distance.  The  skin  of 
the  mortified  part  becomes  discolored,  usually  grayish  or  greenish,  the 
cuticle  separates,  and  when  pressed  upon  obliquely  slides  away  under 
the  finger,  leaving  the  moist  and  slippery  cutis  exposed.  The  color  gradu¬ 
ally  darkens  to  a  dull  purplish  greenish  black,  mottled  in  patches  with 
reddish-brown  spots,  and  after  a  time  there  is  an  odor  of  putrescence 
evolved,  very  commonly  with  an  emphysematous  crackling  from  effusion 
of  gas  into  the  tissues  of  the  part.  The  color  of  the  part  affected  is 
usually  of  a  dark  purplish  or  greenish  black,  more  or  less  mottled  with 


566 


MORTIFICATIONS^,  OR  GANGRENE. 


red.  This,  which  is  unlike  anything  else  in  the  system,  shows  that 
putrefactive  changes  have  taken  place  in  tlie  solids  and  fluids  of  the 
deceased  tissues,  and  is  usuall}’’  connected  with  the  moist  and  swollen 
form  of  the  disease.  In  the  dry  variety  of  gangrene  the  color  is 
often  at  first  of  a  pale  tallowy-white,  with  a  mottled  appearance  upon 
the  surface.  The  skin  soon  shrivels,  becomes  dry,  horny,  and  semi¬ 
transparent,  and  eventually  assumes  a  brown  wrinkled  appearance ;  in 
other  cases  the  gangrened  part  is  brown,  dry,  and  shrivelled  from  the 
very  first.  These  difierences  in  the  color  of  the  mortified  part  indicate 
corresponding  differences  in  the  cause  of  the  affection.  In  general  terms 
it  may  be  stated  that  the  dark  varieties  of  gangrene  are  the  result  of 
destructive  changes  taking  place  in  the  very  part  itself,  or  are  of  con¬ 
stitutional  origin ;  whilst  the  pale  form  of  the  affection  occurs  as  a  - 
consequence  of  some  obstruction  to  the  supply  of  blood  to  the  part,  and 
is  a  local  disease,  influencing  the  constitution  secondarily.  But  it  must 
be  borne  in  mind  that  gangrene  may  have  occurred,  that  is  to  say,  that 
the  part  may  have  lost  its  vitalit^q  wdthout  having  become  dark,  fetid, 
or  emphysematous.  These  signs,  though  sometimes  contemporaneous 
w'ith  loss  of  vitality,  are  more  frequently  consecutive  to  it,  and  indicate 
more  than  the  simple  death  of  the  part ;  the}^  are  proofs  of  putrescence 
having  set  in,  as  well  as  of  death  having  occurred. 

Constitutional  Symptoms. — These  vary  greatly.  When  the  dis¬ 
ease  is  strictly  local,  affecting  a  part  of  but  limited  extent,  and  perhaps 
of  no  great  importance  to  the  econom^q  they  are  not  very  strongly 
marked.  If,  however,  the  gangrene,  although  limited,  implicate  impor¬ 
tant  organs,  as  a  knuckle  of  intestine  for  example,  marked  symptoms 
declare  themselves.  Whatever  the  precursory  condition  may  be,  the  full 
invasion  of  the  gangrene,  if  it  be  rapid,  is  alwa3"s  accompanied  b}^  con¬ 
stitutional  disturbance  of  an  asthenic  type,  attended  by  great  depression 
of  the  powers  of  the  system,  with  a  dull  and  anxious  countenance,  and 
a  feeble,  quick,  and  easily"  compressible  pulse  ;  the  tongue  is  brown,  and 
soon  becomes  loaded  with  sordes.  When  the  gangrene  is  internal, 
sudden  cessation  of  pain,  with  hiccup,  vomiting,  and  tympanitic  disten¬ 
sion  of  the  abdomen,  ma}^  be  superadded  to  the  symptoms,  and  indicate 
the  mischief  that  has  occurred.  Death  usually  supervenes  with  low 
delirium,  twitchings,  and  coma.  When  the  invasion  of  the  gangrene  is 
more  gradual,  as  in  some  of  the  constitutional  forms  affecting  the  lower 
extremities,  the  symptoms  are  usuall}^  those  of  irritative  fever,  eventuall}^ 
subsiding  into  the  asthenic  form. 

Causes. — The  causes  of  gangrene  are  various.  They  may  be  arranged 
under  four  principal  heads. 

1.  Traumatic  Causes  of  various  kinds,  acting  immediately  on  the 
part,  give  rise  to  different  forms  of  gangrene.  Thus,  gangrene  of  a  part 
ma}"  be  produced  when  the  vitalit}^  of  its  tissues  is  destroyed  by  severe 
contusion  or  laceration ;  or  by  an  irritating  fluid ;  or  by  exposure  to 
intense  heat  or  cold. 

2.  Arrest  of  the  Supply  of  Arterial  Blood  to  a  part  is  a  common  cause 
of  gangrene.  It  ma}’^  be  produced  either  by  injury  or  from  disease. 

3.  Obstruction  of  the  Circulation  through  a  part  may  cause  gangrene. 
Under  this  head  are  to  be  classed  those  forms  of  gangrene  which  arise 
from  inflammation,  and  those  in  which  the  return  of  blood  through  the 
principal  veins  is  interfered  with. 

4.  Specific  Poisons  of  various  kinds  occasion  special  diseases  of  which 
gangrene  is  the  principal  characteristic.  Thus,  hospital  gangrene,  malig- 


GAXGREXE  FROM  ARTERIAL  OBSTRUCTION. 


567 


nant  pustule,  cancrum  oris,  carbuncle,  and  ergotism,  are  instances  of 
specific  affections  accompanied  bv  gangrenous  action. 

•  Amongst  the  causes,  some  are  Constitutional^  others  Locals  in  their 
action.  Those  forms  of  ofans^rene  are  said  to  be  constitutional  which 
arise  from  intense  or  specific  infiammation  of  the  part ;  from  obstruction 
of  the  circulation  in  consequence  of  disease  of  the  heart  and  vessels;  or 
from  the  action  of  various  specific  poisons.  On  the  other  hand,  those 
varieties  of  gangrene  are  local  wliich  arise  from  injuries  of  all  kinds, 
whether  applied  to  the  part  itself,  or  to  the  main  artery  leading  to  it,  by 
its  ligature  or  wound. 

These  forms  of  gangrene  which  arise  from  traumatic  causes,  have  been 
alreadj"  described  in  previous  chapters  (see  pp.  ITS,  216,  226,  267)  ; 

,  while  .those  that  arise  from  obstructed  circulation  to  or  through  a  part, 
or  that  take  the  form  of  specific  disease,  are  left  for  consideration  here. 

Gangrene  from  Arrest  of  the  Supply  of  Arterial  Blood. — 
When  a  part  of  the  body  is  deprived  of  its  proper  supplj^  of  blood, 
mortification  may  ensue.  This  we  see  occasionally  happen  when  the 
circulation  through  the  main  arteiy  of  a  limb  is  arrested  by  a  ligature 
or  wound.  Most  commonl}',  when  the  principal  trunk  of  an  artery  is 
obstructed,  the  collateral  circulation  is  sufficient  to  maintain  the  vitality 
of  the  part ;  but,  should  this  be  interfered  with,  gangrene  ensues  from  the 
simple  deprivation  of  blood.  Indeed,  the  sudden  loss  of  a  large  quantiW 
of  blood  from  the  system  generally  may  occasion  the  death  of  some  of 
the  extreme  parts  of  the  body,  in  which  the  circulation  is  naturally  most 
languid.  Thus  Sir  B.  Brodie  relates  the  case  of  a  drunken  man,  who, 
being  bled  to  an  inordinate  extent,  was  seized  with  gangrene  of  both 
feet. 

The  want  of  a  due  supply  of  arterial  blood  to  the  limb  may  be  occa¬ 
sioned  by  two  primary  sets  of  causes:  a,  from  injury  or  operation^  as 
wound  or  ligature  of  the  main  trunk;  6,  from  disease^  as  by  thrombosis 
or  by  embolism;  by  calcification^  and  consequent  occlusion  of  the  vessel. 
Gangrene  from  arterial  obstruction  varies  materially  in  its  symptoms, 
prognosis,  and  treatment,  according  as  it  arises  from  one  or  other  of 
these  causes.  When  the  obstruction  is  seated  in  the  arteries  alone,  the 
gangrene  will  be  of  the  dry  kind ;  but  when  there  is  also  an  impediment 
to  the  return  of  blood  from  the  part,  the  disease  will  partake  more  or 
less  of  the  character  of  the  moist  variety. 

a.  A  limb  gangrenous  in  consequence  of  the  Ligature  or  Wound  of  its 
Main  Artery.,  without  any  other  injuiy  to  the  vascular  S3^stem,  becomes 
cold,  feels  heavy,  and  loses  its  sensibilit}" ;  at  the  same  time  it  assumes 
a  dull  tallow3"-white  color,  mottled  with  grajdsh  or  brownish  streaks. 
This  state  of  things  is  chiefly  met  with  in  the  lower  extremit}^ ;  the 
integuments  of  the  foot  die,  becoming  semitransparent  and  horn^Aooldng 
where  the^^  are  stretched  over  the  tendons  of  the  instep,  and  the  part 
presents  a  shrivelled  appearance.  In  a  short  time  the  pallid  color  is 
lost,  the  part  becoming  brown  or  blackish.  This  form  of  gangrene  ma}' 
invade  the  whole  of  the  lower  limb,  but  most  commonlj^  is  limited  to  the 
foot,  stopping  either  just  above  the  ankle,  or  if  not,  then  immediateh’ 
below  the  knee,  as  Guthrie  has  observed  ;  the  arrest  taking  place  in  one 
or  other  of  these  two  spots,  on  account  of  the  greater  freedom  of  the 
collateral  circulation  here  than  in  other  parts  of  the  limb.  If  anj^  of  the 
large  venous  trunks  become  obstructed  or  otherwise  implicated,  so  that 
the  return  of  blood  through  them  is  interfered  with  at  the  same  time 
that  the  supply-  b^^  the  arteries  is  arrested,  the  limb  generall}^  assumes  a 
greenish-blue  color,  and  rapidly  runs  into  putrefaction.  In  some  of  these 


568 


MOETIFICATION,  OR  GANGRENE. 

cases  it  happens  that  sloughs  of  the  integument  and  subcutaneous  areolar 
tissue  form,  although  the  limb  generally  preserves  its  vitality.  The 
treatment  of  these  forms  of  gangrene,  which  are  strictly  local,  is  de¬ 
scribed  in  the  chapter  on  the  Arrest  of  Arterial  Hemorrhage  (pp.  267- 
269). 

b.  Gangrene  may  occur  from  the  circulation  being  arrested  by  obstruc¬ 
tion  arising  in  the  coats  of  the  arteries,  or  in  the  contained  blood.  This 
is  the  variety  of  the  affection  that  is  commonly  called  Spontaneous.  It 
may  be  the  result  of  thrombosis  or  emboljsm  in  a  previously  healthy 
artery,  or  of  the  plugging  up  of  an  artery  that  has  undergone  calcification 
or  senile  degeneration. 

Spontaneous  gangrene  from  the  formation  of  Thrombosis,  or  clot  in  the 
arteiy,  usually  occurs  in  young  or  middle-aged  persons.  Whether  the 
thrombosis  be  the  result  of,  or  the  antecedent  to,  inflammation  within  the 
vessel,  is  a  question  which  need  not  be  discussed  here.  In  either  case, 
when  gangrene  from  this  cause  appears,  w'e  meet  with  the  usual  signs  of 
arteritis,  sueh  as  tenderness  along  the  course  of  the  vessel,  cessation  of 
pulsation  in  its  terminal  branches,  and  intense  superficial  pain  in  the 
limb,  followed  by  the  rapid  supervention  of  dark  dry  gangrene  in  the 
whole  of  the  extremity  up  to  the  point  at  which  the  vessel  is  inflamed. 
In  some  cases  the  gangrene  partakes  of  the  characters  of  the  humid  form, 
owing  to  the  implication  of  the  contiguous  veins.  It  is,  I  believe,  most 
frequently  met  with  in  the  upper  extremities ;  at  least,  most  of  the 
instances  of  it  that  I  have  seen  have  been  situated  there.  I  have  ob¬ 
served  it  most  commonW  in  women,  occurring  sometimes  at  an  early 
period  of  life,  even  at  the  eighteenth  year.  Its  causes  are  very  obscure  ; 
in  some  cases  the  disease  appears  to  be  of  rheumatic  origin,  in  others 
it  is  connected  with  a  cachectic  and  broken  state  of  constitution.  It 
frequentl}"  proves  fatal  by  the  supervention  of  typhoid  symptoms,  before 
any  attempt  can  be  made  by  nature  to  separate  the  mortified  part.  After 
death,  the  affected  vessel  is  found  firmly  plugged  at  the  seat  of  obstruc¬ 
tion  by  a  dense  coagulum,  which  completely  impedes  the  circulation 
through  it. 

Gangrene  may  also  be  produced  by  Embolon,  the  terminal  branches 
of  the  arteries  and  the  capillary  vessels  becoming  plugged  by  a  mass  of 
finely  granular  fibrinous  matter,  w'hich  is  washed  down 
and  into  the  lower  part  of  the  vessel  from  the  inflamed 
patch  on  the  inner  surface  of  the  artery  at  a  higher  point. 
In  peculiar  conditions  of  the  blood,  at  present  of  an  uncer¬ 
tain  charaeter,  this  plugging  is  more  specially  apt  to  occur. 
In  some  cases  the  embolon  appears  to  consist  of  a^  plug  of 
plastic  matter  which  has  been  detached  from  a  distant  part 
of  the  circulatory  apparatus,  from  the  interior  of  the  left 
ventricle  for  instance,  and,  being  carried  by  the  circulation 
into  the  arterial  system,  stops  at  some  point  of  bifurcation 
or  of  narrowing  of  a  vessel.  In  such  cases  the  gangrene 
may  develop  itself  suddenly.  The  accompanying  drawing 
(Fig.  206)  represents  the  bifurcation  of  the  common  femoral 
arteiy  occupied  by  a  fibrinous  plug,  taken  from  a  man  aged 
Femorir  Artery  62,  wdio  died  of  gangrene  of  the  left  leg.  In  this  case  the 
at  its  Bifurcation  patient,  after  recovering  from  rheumatic  endocarditis,  whilst 
by  an  Embolon.  Straining  at  stool.  Suddenly  felt  his  left  leg  tingle  painfully, 
then  become  numb  and  cold.  The  circulation  in  it  ceased, 
and  gangrene  speedily  supervened,  which  extended  as  high  as  the  knee. 
Death  followed  amputation  of  the  limb.  Here  there  can  be  little  doubt 


GANGRENE  FROM  ARTERIAL  OBSTRUCTION. 


569 


Fig. 


208. 


that  the  siulden  supervention  of  gangrene  was  the  result  of  obstruction 
to  the  arterial  circulation  of  the  lower  extremity,  consequent  on  the 
detachment  of  a  fibrinous  endocardial  plug,  and  its  arrest  at  the  bifurca¬ 
tion  of  the  femoral  artery. 

Spontaneous  gangrene  is  termed  Senile  when  it  occurs  in  old  people  in 
consequence  of  the  Goats  of  the  Arteries  becoming  Rigid  and  Calcified 
(Fig.  20T),  and  unable  to  maintain  the  proper  circulation  of  blood  through 
the  limb.  The  want  of  a  due  supply  of  arterial  blood  in 
these  cases  is  not  only  owing  to  the  diseased  state  of  the  Fig-  207. 
arteries,  but  is  in  a  great  measure  due  to  the  feeble  pro¬ 
pulsive  power  of  the  heart,  and  the  consequent  naturally 
weakened  circulation  through  the  lower  limbs  especially. 

When  the  circulation  is  so  enfeebled  as  to  cause  the 
nutrition  of  the  limb  to  be  lowered,  coldness,  cramps,  and 
in  some  cases  cutaneous  ulcerations,  will  ensue.  When 
the  circulation  becomes  arrested  from  the  conjoined  influ¬ 
ences  of  diminished  cardiac  propulsive  power  and  arterial 
obstructions,  gangrene  inevitably  results.  It  is  met  with 
in  the  lower  extremities  of  people  past  the  middle  period 
of  life,  and  the  tendency  to  it  increases  as  age  advances. 

The  premonitory  S3nnptoms  are  as  follows.  A  sensation 
of  weight  in  the  limb,  with  coldness,  itching,  and  tingling 
in  the  feet,  and  with  cramps  in  the  calves,  is  complained 
of,  and  the  circulation  of  the  part  is  habitually  defective, 
the  pulsation  of  the  tibials  being  scarcel^^  perceptible. 

This  condition  commonly  exists  for  a  con¬ 
siderable  length  of  time  before  gangrene 
actually  comes  on,  and  should  alwa^^s  be 
looked  upon  with  anxiety  in  old  people.  In 
many  instances  the  disease  sets  in  without 
aii}^  exciting  cause ;  but  in  other  cases  the 
mortification  is  immediatelj’’  developed, 
as  the  result  of  some  slight  inflammation 
accidental^  induced,  as  from  the  excoria¬ 
tion  produced  b^^  a  tight  boot,  or  from  a 
trivial  wound  in  cutting  a  corn  or  toe-nail ; 
the  inflammation  occasioned  by  this  slight 
inj  ury  being  sufficient  to  disturb  the  balance 
of  the  circulation  in  the  already  weakened 
part  to  so  great  an  extent,  that  gangrene 
ensues.  In  other  instances,  again,  the 
disease  is  ushered  in  by  more  acute  symp¬ 
toms.  The  whole  foot  becomes  swollen, 
cedematous,  and  red;  inflammation,  appa¬ 
rently  of  a  gouty  character,  being  set  up 
in  it.  In  whatever  w^ay^  it  begins,  the 


Senile  Gangrene 
Exposure  of  Bones 
of  Foot. 


Femoral  and 
Tibial  Arteries  ob¬ 
structed  in  Senile 
Gangrene. 


gangrene  may  at  first  only  effect  one  toe,  or  it  maj^  from  the  commence¬ 
ment  involve  several.  It  most  generally"  in  the  first  instance  appears  in 
the  form  of  a  cold  purple  or  blackish-red  spot  on  the  side  of  one  of  the 
toes,  usuall}’  the  inner  side  of  the  great  toe ;  this  spot  may  be  surrounded 
by  an  inflamed  areola,  and  accompanied  by  much  smarting  and  burning 
pain  of  a  parox3^smal  character;  it  spreads  by  gradually  involving  the 
inflamed  areolar,  which  continues  to  extend  in  proportion  as  the  gangrene 
progresses.  The  pain,  which  is  often  of  the  most  intense  character,  sub¬ 
sides  when  the  gangrene  becomes  complete.  In  other  cases  the  toes  and 


570 


MORTIFICATION,  OR  GANGRENE. 

foot  simply  shrivel,  without  any  sign  of  local  inflammation  and  with  but 
little  constitutional  disturbance.  In  one  or  other  of  these  ways  the 
affection  gradually  creeps  up  the  limb,  invading  perhaps  one  toe  after 
the  other,  involving  the  instep  (Fig.  208),  the  heel,  or. the  sole  of  the 
foot ;  and  unless  it  terminate  by  the  formation  of  the  line  of  demarcation, 
or  death  put  an  end  to  the  patient’s  sufferings,  it  may  extend  up  the 
ankle  or  leg.  The  part  that  is  destroyed  is  always  black,  diy,  and 
shrivelled,  resembling  closely  in  appearance  a  dried  mummy ;  hence 
the  change  is  often  termed  mummification  (Fig.  209).  The  toes  often 
look  like  the  shrivelled  skins  of  over-ripe  or  sucked-out  black  grapes. 
There  is  usually  considerable  constitutional  disturbance,  sometimes 
pyrexial  at  first,  but  secondarily  sinking  into  an  irritative  or  asthenic 
form  ;  and  the  disease  is  often  fatal  in  Irom  a  montii  to  six  weeks.  But 
this  is  very  uncertain.  I  have  known  the  disease  to  continue  with  very 
little  constitutional  disturbance  for  more  than  twelve  months,  slowly 
creeping  on  during  that  time.  In  other  instances,  the  gangrene  being 
limited  to  a  small  extent,  as  to  the  toes  only,  the  patient  may  recover 
with  the  loss  of  the  forepart  of  the  foot.  The  pathology  of  the  arterial 
system,  in  reference  to  these  forms  of  gangrene,  will  be  more  fully 
discussed  in  the  first  chapter  of  Volume  II. 

Gangrene  from  Obstruction  of  the  Circulation  through  a 
Part. — This  may  occur  in  three  ways:  I,  by  Venous  Obstruction^  Sind 
consequent  over-accumulation  of  blood  ;  2,  by  the  arrest  of  all  the  blood, 
arterial,  venous,  and  capillary,  as  in  Strangulation  by  a  tight  ligature  ; 
3,  by  Inflammation. 

1.  Venous  Obstruction. — Gangrene  may  arise  from  obstruction  to  the 
return  of  blood  through  the  veins  of  a  part,  the  circulation  being  arrested 
by  the  overloading  of  the  capillaries  with  venous  blood.  It  is  especially 
apt  to  take  place  if  the  arterial  supply  be  diminished  at  the  same  time 
that  the  return  of  venous  blood  is  interfered  with  ;  as  when  an  artery  and 
vein  are  compressed,  or  when  the  femoral  vein  is  wounded  accidentally 
at  the  time  when  the  artery  is  ligatured.  Gangrene  from  this  cause  is 
always  of  the  moist  kind,  attended  by  much  oedema,  with  discoloration 
and  rapid  putrefaction  of  the  part. 

This  gangrene  from  venous  obstruction  is  also  especially  apt  to  occur 
in  those  cases  in  which  the  heart’s  action  is  weakened,  so  that  the  force 
of  the  impulse  in  the  arterial  s^^stem  is  so  lowered  as  to  be  unable  to  push 
the  blood  through  the  loaded  veins.  Those  cases  of  gangrene  of  the  ex¬ 
tremities  that  are  met  with  from  pure  debility,  as  after  fevers,  often 
appear  to  originate  in  this  wa3^ 

2.  Strangulation. — A  part  is  often  purposely  strangled  by  a  Surgeon 
in  operative  procedures;  or  its  circulation  may  in  this  way  be  arrested 
as  the  result  of  certain  accidents  or  diseased  conditions  (see  p.  167).  In 
either  case,  the  strangulation  acts  b}’  stopping  more  or  less  completel}^ 
the  whole  circulation  of  the  part.  If  it  be  sufficiently  severe,  it  may  kill 
the  tissues  outright :  for  instance,  when  a  nsevus  or  a  pile  is  tied,  all  fiow 
of  blood  to  or  from  the  part  is  suddenly  arrested,  and  its  vitality  is 
destroyed,  the  tissues  that  have  been  strangled  shrivelling  and  separa¬ 
ting  by  ulceration  along  the  line  of  ligature.  When  the  strangulation 
is  not  so  severe  as  this,  great  congestion  ensues,  consequent  on  the 
amount  of  blood  sent  into  the  part  being  greater  than  can  be  removed 
b}^  the  veins,  which  are  more  affected  by  tlie  constricting  force  than 
the  arteries;  the  part  strangled  becomes  dark  and  congested,  phlyctense 
or  vesicles  arise  on  its  surface,  and  effusion  takes  place  into  its  tissue  ; 
inflammation  becomes  at  last  superadded  to  the  effects  of  the  strangu- 


GANGRENE  FROM  OBSTRUCTED  CIRCULATION.  571 


lation,  and  still  more  embarrasses  the  circulation  of  the  part;  and 
thus  sloughing  arises,  from  the  conjoined  action  of  the  strangulation  and 
the  inflammation.  All  this  we  see  occurring  in  the  constricted  gut  of  a 
strangulated  hernia. 

3.  Inflammation. — Deferring  for  the  present  the  consideration  of  cer¬ 
tain  specific  forms  of  inflammatory  disease  that  are  liable  to  be  attended 
with  gangrene,  we  have  here  to  consider  the  death  of  parts,  when  it 
occurs  as  a  sequence  of  ordinary  inflammation.  The  production  of  gan¬ 
grene  by  inflammation,  or  rather,  perhaps,  by  the  congestion  forming 
part  of  it,  is  a  less  simple  affair  than  its  production  in  either  of  the  wa3^s 
which  we  have  already'  described.  Sir  James  Paget  remarks  that  in  cer¬ 
tain  forms  of  gangrene  after  inflammation,  all  the  more  simple  ordinar}* 
causes  of  mortification  may  be  involved  along  with  others ;  thus,  “  1. 
The  inflammatory  congestion  may  end  in  stagnation  of  the  blood ;  and 
this,  as  an  indirect  cause  of  mortification,  ma}^  lead  to  the  death  of 
the  blood  and  that  of  the  tissues  which  need  moving  blood  for  their  sup¬ 
port.  2.  A  degeneration  of  the  proper  textures  is  a  constant  part  of  the 
inflammatory  process;  and  this  degeneration  may  itself  proceed  to  death, 
while  it  is  concurrent  with  defects  in  the  conditions  of  nutrition.  3. 
The  exudation  of  fluid  in  some  inflamed  parts  ma^'  so  compress,  and  b}’ 
the  swelling  so  elongate  the  bloodvessels,  as  to  diminish  materiall}"  the 
influx  of  fresh  blood,  even  when  little  of  that  already  hi  the  part  is 
stagnant.” 

The  intensity  of  the  inflammation  may  be  so  great  as  to  kill  the  part 
direct!}",  however  healthy  its  texture  or  sound  the  constitution  of  the 
patient  may  be.  More  commonly,  however,  it  is  not  so  much  the  actual 
as  the  relative  intensity  of  the  inflammation  that  destroys  the  part ; 
there  being  some  debility,  local  or  constitutional,  by  which  the  resisting 
or  preservative  power  is  lessened.  Paget  says  that  the  gangrene  here 
seems  to  arise  especially  in  persons  whose  tissues  have  become  degenerate 
in  consequence  of  old  age,  of  defective  food  or  other  materials  of  life,  or 
through  habitual  intemperance ;  the  disturbance  of  local  nutrition,  which 
forms  part  of  the  inflammatory  process,  being  greater  than  the  enfeebled 
tissues  can  resist  or  overcome.  It  is  remarkable  to  observe  what  slight 
injuries  will  induce  gangrenous  inflammation  in  these  circumstances. 
The  nature  of  the  tissue  exercises,  however,  considerable  influence  ;  thus, 
with  a  moderate  amount  of  inflammation,  some  tissues  very  readily  run 
into  gangrene,  the  areolar  membrane  especially  being  apt  to  do  so ;  whilst 
others,  as  the  proper  tissue  of  glands  and  organs,  are  seldom  so  aflfected. 

The  specific  character  of  the  inflammation  influences  greatly  the  dis¬ 
position  to  gangrene ;  some  forms,  as  the  carbuncular,  invariably  result¬ 
ing  in  the  loss  of  Autality  of  the  part.  In  some  states  of  the  constitution, 
the  blood  appearing  to  be  diseased,  there  is  a  great  liability  to  gangrene. 

Gangrene  consequent  on  inflammation  is  of  the  moist  or  acute  kind, 
being  always  connected  with  a  retention  of  blood  in  the  part  affected. 
We  may  regard  it  as  impending  in  a  part  that  has  become  inflamed  from 
injury  or  other  cause,  if  we  find  that  the  redness  becomes  of  a  dusky  or 
purplish  hue;  that  bullae  filled  with  dark  fluid  rise  upon  the  surface;  that 
the  swelling,  at  first  hard,  tense,  and  brawny,  becomes  of  a  pulpy  or 
doughy  character ;  that  the  pain  is  of  a  dull,  heavy,  or  burning  kind  ; 
and  that  the  temperature  of  the  part,  at  first  greatly  increased,  gradually 
sinks.  We  know  that  gangrene  has  taken  place  when  there  is  a  total 
loss  of  the  sensibility  of  the  part,  even  to  pricking  or  pinching ;  that 
the  motion  of  the  part  itself  ceases  ;  that  its  color  changes  to  a  peculiar 
mottled,  purplish-red,  or  greenish-black  hue,  unlike  anything  else  in  the 


572 


MORTIFICATION,  OR  GANGRENE. 

body;  that  the  temperature  falls  to  a  level  with  that  of  surrounding 
media  ;  or  that  the  surface  affected  ma}’,  b}^  evaporation,  even  feel  colder. 
There  is  likewise  an  odor  evolved,  differing  from  that  of  ordinary  post¬ 
mortem  decomposition,  and  evidently  depending  upon  gaseous  exhala¬ 
tions  from  the  part  that  has  l(»st  its  vitality,  and  has  at  the  same  time 
become,  while  retained  in  connection  with  the  living  parts,  the  seat  of 
putrefactive  changes.  The  extent  of  tissue  affected  ma}^  vary  from  a  mere 
spot  to  the  implication  of  the  greater  portion  of  a  limb  ;  and  the  gangrene 
appears  to  be  finally  arrested  by  the  inflammation  losing  its  force  as  it 
radiates  from  the  centre,  until  it  reaches  a  part  where  it  is  sufficiently 
reduced  to  be  compatible  with  these  processes  of  separation  and  repair 
which  will  immediately  be  described. 

The  Constitutional  Symptoms,  always  of  a  low  type,  vary  according  to 
circumstances.  If  the  blood  be  healthy,  and  the  constitution  sound,  the 
gangrene  occurring  as  the  consequence  of  severe  injury,  the  symptoms 
will  present  the  ordinary  character  of  inflammatory  fever,  though  even 
in  these  cases  there  is  a  great  tendency  to  asthenia.  If  the  constitution 
be  broken,  or  the  blood  in  a  diseased  state,  the  constitutional  symptoms 
will  rapidly  run  into  the  irritative  form. 

Arrest  of  Gangrene. — Certain  forms  of  gangrene  (see  p.  n9)have 
a  tendency  to  extend  indefinitely  until  the  patient  succumbs  to  the  dis¬ 
ease.  In  many  instances,  however,  the  progress  of  the  mortification  is 
arrested,  and  the  dead  parts  are  separated  from  the  living.  When  the 
gangrene  reaches  a  part  of  which  the  vitality  is  too  great  to  be  destroyed 
by  the  causes  which  have  produced  it,  a  line  of  demarcation  is  formed. 
This  line  is  a  kind  of  barrier  or  septum  of  plastic  matter,  poured  out 
into  the  interstices  of  the  healthy  tissues  at  their  extreme  limits  next 
the  gangrene ;  the  line  indeed,  along  which  the  dead  and  living  parts 
touch.  It  extends  along  the  whole  depth  of  the  gangrene,  completel}’’ 
surrounding  it  on  all  its  attached  sides.  It  appears  to  be  formed  exactly 
by  the  same  process,  and  by  the  same  mechanism,  as  that  by  which 
l3"mph  is  effused  around  any  foreign  body  or  fluid  accumulation  that  has 
lost  its  vitality.  Just  as  lymph  forms  the  boundaiy  wall  to  extravasa¬ 
tion  of  blood,  or  to  accumulation  of  pus,  so  it  forms  a  barrier,  deposited 
in  the  living  tissues,  to  separate  them  from  the  dead  structures  bej^ond, 
which  by  their  veiy  loss  of  vitality  have  become  foreign  to  the  healthy 
structures  in  their  neighborhood.  The  inflammation,  if  any  be  present, 

is  reduced  in  intensity"  at  this  part ; 
it  does  not,  however,  cease  ab¬ 
ruptly,  but  fades  away  in  the 
health}^  structures  bej^ond  it. 

When  the  gangrene  is  arrested, 
nature  throws  off  the  spoilt  parts, 
not  by  a  process  of  disintegration 
or  falling  to  pieces  of  these  parts, 
but  by  a  vital  act — a  process  of 
ulceration,  extending  through  the 
line  of  demarcation,  and  loosening 
the  slough  or  necrosed  tissue  bv 
the  absorption  of  that  layer  of 
living  tissue  which  lies  next  to  it. 
This  line  of  ulceration  is  termed 
the  line  of  separation,  and  extends  itself  along  the  extreme  margin  of 
the  living  tissues  (Fig,  209). 

This  process  of  separation,  commencing  at  the  edge  of  the  slough, 


Fig.  209. 


TEEATMEXT  OF  GAXGREXE. 


573 


which  graduallj’  loosens,  slowly  extends  downwards  to  the  whole  depth 
of  the  grangrene  ;  if  this  affect  the  entire  thickness  of  the  limb,  the 
ulceration  will  find  its  way  completely  across  it.  If  the  slough  be  more 
superficial,  the  ulcerative  action  passes  underneath  it,  detaching  it  gradu¬ 
ally.  The  line  of  separation  is  usually  oblique,  the  soft  parts  being  first 
divided,  and  the  hard  tissues  then  ulcerated  through,  until  the  ligamen¬ 
tous  or  osseous  structures  are  reached,  which  are  slowl}"  acted  upon. 
As  the  ulceration  extends  across  the  limb,  the  largest  arteries  and  veins 
are  cut  through  by  it,  without  hemorrhage  resulting,  owing  to  a  mass  ot 
plastic  matter  being  poured  out  in  their  interior,  and  blocking  them  up 
from  the  line  of  separation  to  the  nearest  large  collateral  branch  above 
it.  The  period  required  for  the  detachment  of  gangrenous  parts  varies 
according  to  their  extent.  Small  sloughs  may  be  detached  in  a  few  days, 
whilst  many  weeks  are  required  for  the  separation  of  a  limb.  The  action 
is  most  rapid  in  the  soft  tissues  and  in  3'oung  subjects. 

After  the  separation  of  the  gangrened  part,  a  more  or  less  ragged 
irregular  ulcerated  surface  is  left,  which,  if  not  too  extensive,  and  the 
patient’s  reparative  powers  be  in  a  favorable  state,  will  undergo  cicatri¬ 
zation  by  the  same  process  as  in  ordinaiy  ulcers.  This  indeed,  com¬ 
mences  while  the  separation  is  gaing  on;  granulations  graduall}'  appear¬ 
ing  in  that  part  of  the  line  of  separation  which  has  effected  its  purpose 
of  cutting  off  the  dead  from  the  living  parts. 

Diagnosis. — The  diagnosis  is  easily'  effected  when  gangrene  has 
full}"  developed  itself ;  but  in  the  earl 3^  stages,  before  it  is  positively 
declared,  it  is  not  alwa3"s  eas}"  to  determine  its  existence.  The  ecch}"- 
mosis  and  discoloration  of  a  bruise,  the  collapse  and  lividit}"  that  result 
from  cold,  or  the  dark  purple  hue  occasioned  by  long-continued  conges¬ 
tion,  may  readily  be  confounded  with  impending  gangrene.  In  these 
cases  of  doubt,  the  Surgeon  should  not  be  in  too  great  a  hurr}^  to  pro¬ 
nounce  an  unfavorable  opinion,  and  still  less  to  act  upon  it ;  for  not 
uncommonl}"  parts  of  the  body  which  have  to  all  appearance  lost  their 
vitalit}^  ma}^  under  proper  treatment,  regain  it. 

Prognosis. — So  far  as  the  part  itself  is  concerned,  the  prognosis  is 
alwa3"s  bad  ;  though  occasionall}^  when  gangrene  has  not  been  full}' 
established,  partial  recover}'  ma}^  unexpected!}'  take  place.  So  far  as 
the  life  of  the  patient  is  at  stake,  much  will  depend  on  the  cause  of  the 
affection,  and  on  the  age  and  strength  of  the  individual ;  at  advanced 
periods  of  life,  and  in  a  feeble  state  of  the  system,  the  result  is  always 
unfavorable.  Also  whilst  the  gangrene  is  spreading,  the  prognosis  is 
bad,  as  it  is  impossible  to  say  where  the  morbid  action  may  stop;  but 
when  a  “  line  of  demarcation”  has  formed,  indicating  the  possession  of 
a  certain  vigor  of  consti^tution,  the  principal  danger  is  over,  and  the 
result  will  depend  on  the  j^ower  of  the  patient,  and  the  support  that  can 
be  given  during  the  processes  of  separation  and  of  repair. 

Treatment. — As  gangrene  proceeds  from  a  great  variety  of  causes, 
it  must  be  very  evident  that  no  one  plan  of  treatment  can  be  universally 
applicable ;  and  it  becomes  necessary  to  modify  our  therapeutic  and 
operative  means,  not  only  according  to  the  cause  of  the  disease,  but  also 
with  special  reference  to  the  constitution  of  the  patient,  and  with  regard 
to  the  stage  in  which  we  meet  with  the  gangrene ;  and,  indeed,  it  often 
requires  great  tact  and  experience  to  accommodate  the  treatment  in  this 
way  to  the  varying  phases  of  the  case. 

The  Constitutional  Treatment  of  grangrene  is  of  the  highest  import¬ 
ance  ;  of  greater  moment,  indeed,  in  the  spontaneous  forms  of  the  affection 
than  the  local  management  of  the  disease.  It  has  three  principal  aims  : 


574 


MORTIFICATION,  OR  GANGRENE. 


1.  To  remove  the  cause  if  possible,  and  thus  to  arrest  the  gangrene.  2. 
To  support  the  powers  of  the  system  during  the  process  of  the  separation 
of  the  sloughs  and  dead  tissues;  and  3.  To  lessen  the  irritability  of  the 
nervous  system. 

1.  In  the  removal  of  the  constitutional  cause ^  we  must  look  wholly 
to  the  condition  of  the  patient’s  system.  If  this  be  in  an  inflammatory 
or  febrile  state,  we  must  have  recourse  to  a  modified  anti-inflammatory 
plan.  Depressing  remedies  must  be  very  sparingly  used,  the  patient’s 
condition  being  usually  not  of  such  a  nature  as  to  bear  lowering.  It  is 
very  easy  to  knock  down  inflammation  by  energetic  measures ;  but,  at 
the  same  time,  the  reparative  power  of  the  system  is  destroyed,  and  the 
patient  may  not  be  able  to  rally.  Inflammatory  fever,  however  high  it 
may  be  in  the  earl}'-  stages,  rapidly  sinks  after  gangrene  has  set  in, 
symptoms  of  an  asthenic  or  an  irritative  type  ensuing.  Hence  it  is  only 
before  the  occurrence  and  during  the  spread  of  gangrene,  that  lowering 
remedies  can  be  employed  ;  for,  when  once  gangrene  has  ceased  to 
extend,  however  high  the  action  ma}’  have  been  that  accompanied  its  pro¬ 
gress,  all  the  powers  of  the  constitution  will  be  required  to  maintain  the 
process  of  separation  of  the  sloughs,  if  they  be  extensive  and  deep. 
Venesection  is  never  required  in  any  form  of  gangrenous  inflammation. 
An  enfeebled  state  of  the  circulation  of  the  part  or  the  system  generally 
may  equally  occasion  or  complicate  the  gangrene ;  and  there  may  be 
every  possible  combination  between  this  and  the  active  inflammatory 
condition.  In  these  circumstances,  it  will  be  necessary  to  conjoin  an 
ajiti-inflammatory  plan  of  treatment  with  remedies  of  a  tonic,  or  even 
stimulating  character.  It  is  this  plan  of  treatment  that  is  commonly 
found  to  succeed  best  in  spontaneous  gangrene ;  here  moderate  anti¬ 
inflammatory  remedies  are  perhaps  required  in  the  earlier  stages,  with  a 
light  nutritious  diet  and  mild  tonics  as  the  disease  advances  ;  and  in  the 
latter  periods,  when  the  constitutional  symptoms  become  asthenic, 
stimulants  should  be  given.  The  best  stimulants  are  wine  or  porter, 
according  to  the  patient’s  habits  of  life ;  and  these  should  be  given  in 
combination  with  nourishment,  so  as  not  merely  to  raise  the  pulse,  but 
to  produce  a  more  permanent  tonic  influence  on  the  system  generally. 
If  much  depression  occur,  the  medicinal  stimulants,  especiall}^  ether, 
ammonia,  and  camphor,  are  of  material  service.  The  onl3^  tonics  that 
are  of  much  value  here,  are  the  preparations  of  bark  and  some  of  the 
vegetable  bitters,  as  gentian  and  cascarilla ;  and  though  the  specific 
virtues  that  were  formerly  attributed  to  them  can  no  longer  be  accorded, 
3"et,  when  they  do  not  irritate  the  stomach,  they  are  of  unquestionable 
service  in  combating  the  asthenic  symptoms,  and  improving  the  digestive 
powers.  In  these  cases  I  look  upon  bark  or  gentian,  in  combination 
with  chlorate  of  potass  and  ammonia,  as  of  undoubted  value. 

2.  After  the  proper  employment  of  means  calculated  to  remove  the 
constitutional  cause  of  the  gangrene,  the  system  must  be  supported  against 
the  debilitating  effects  that  accompany  the  process  of  ulceration  and  of 
suppuration  necessary  for  the  separation  of  the  modified  parts.  During 
this  period,  there  are  less  irritation  and  more  debilit}’’,  and  stronger  tonics 
can  be  borne ;  but  we  should  be  careful  not  to  overstimulate  the  patient. 
On  this  point  it  is  extremely"  difficult  to  lay  down  any  rule ;  every  pos¬ 
sible  variety  as  to  the  quantity  and  quality  of  food  and  stimulus  being 
required  by  different  individuals.  The  safest  guides  are  the  state  of  the 
pulse  and  tongue  ;  if  the}’’  improve,  the  means  employed  agree.  At  the 
same  time  hygienic  measures  should  be  carefull}^  attended  to;  cleanliness 
and  free  ventilation,  with  the  abundant  use  of  the  chlorides,  are  of  the 


TREATMENT  OF  GANGRENE. 


^  ^ 

0/0 

first  moment,  so  that  the  patient  may  not  be  poisoned  by  his  own 
exhalations. 

3.  The  third  indication,  that  of  lessening  the  irritability  of  the  system 
that  always  supervenes,  and  which  is  partly  owing  to  the  severity  of  the 
pain,  and  partly  to  the  shaken  and  depressed  state  of  the  nervous  system, 
is  best  carried  out  by  the  administration  of  opium ;  and  although  this 
drug  may  not  act  as  a  specific,  as  Pott  supposed,  3"et  in  many  cases,  but 
especially  in  the  gangrene  of  the  toes  and  feet  of  old  people,  it  is  un¬ 
doubtedly  a  remedy  of  the  greatest  value.  A  grain  of  solid  opium  may 
be  administered  advantageously  every  sixth,  eighth,  or  twelfth  hour, 
according  to  the  effect  wdiich  it  is  found  to  produce ;  care  being  taken 
that  the  bowels  do  not  become  confined.  The  hiccup,  which  is  often  dis¬ 
tressing,  is  best  remedied  by  the  administration  of  chloric  ether  and 
camphor. 

Local  Treatment. — Gangrene,  when  threatening  to  be  the  result  of  in¬ 
flammation,  may  often  be  prevented  by  free  incisions  into  the  inflamed 
and  tense  parts.  Punctures  are  not  sufficient,  but  free  incisions  two  or 
three  inches  long  should  be  made,  which  by  gaping  widely  allow  the 
escape  of  the  blood  and  other  fluids,  and  thus  effectually  relieve  the  ves¬ 
sels  and  the  tissues.  This  is  more  especially  the  case  when  loose  areolar 
tissue,  as  that  of  the  penis  or  scrotum,  is  inflamed  ;  or  indeed  in  any 
part  in  which  much  tension  is  conjoined  with  the  inflammation.  The 
relief  of  local  tension  is  of  the  first  consequence  in  cases  of  inflammation 
threatening  gangrene.  By  a  free  incision  through  a  structure  so  affected, 
as  in  phlegmonous  eiysipelas  or  carbuncle,  not  only  may  the  vitalit}^  of 
the  affected  tissues  be  preserved,  but  the  extension  of  gangrene,  if  it 
have  already  set  in,  is  arrested,  and  the  constitutional  disturbance  is  at 
once  lessened  :  the  strain  on  the  bloodvessels  being  taken  off,  the  pulse 
falls,  loses  its  sharpness,  and  great  relief  is  afforded.  In  some  forms 
of  inflammatory  sloughing,  nature  relieves  the  part  by  free  hemorrhage, 
as  from  the  dorsal  arteiy  in  cases  of  acute  gangrene  of  the  penis  ;  and  it 
is  not  until  this  has  taken  place,  that  the  gangrenous  action  becomes 
arrested.  By  incision,  also,  irritant  effusions  and  infiltrations  are  dis¬ 
charged,  and  thus  one  cause  of  sloughing  is  removed.  Mild  local  anti¬ 
inflammatory  treatment  of  an  ordinary  character  is  likewise  required. 

When  the  gangrene  has  been  arrested,  i\\Q  fetor  of  the  sloughs  must  be 
diminished  b}"  antiseptic  applications,  such  as  the  solutions  of  the  chlo¬ 
rides,  carbolic  acid,  or  charcoal  and  3’east  poultices.  The  separation  of  the 
sloughs  should  be  left  as  much  as  possible  to  nature,  which  is  always  fully 
able  to  accomplish  this,  if  the  patient’s  strength  can  be  kept  up.  The 
vitality  of  the  tissues  in  the  proximity  of  and  above  the  line  of  separation 
is  veiy  low,  and  may  readily  be  destro3^ed  by  any  fresh  action  set  up  in 
them,  there  being  alwa3’S  a  danger  of  exciting  inflammation  to  such  a 
degree  as  to  exceed  that  which  is  necessary  for  the  adhesive,  and  to  cause 
it  to  run  into  the  gangrenous  form.  Hence  no  attempt  should  be  made 
to  pull  away  sloughs  not  already  separated,  nor  should  stimulants  be 
applied  to  the  living  tissues.  It  matters  little  as  to  what  is  done  to  parts 
already  dead,  which,  when  loosened,  may  be  cut  awa3^ ;  but  we  must  not 
meddle  with  those  that  are  livins:.  Hemorrhage  seldom  occurs  before 
the  separation  of  the  sloughs,  but  there  is  always  danger  of  it  happening 
during  that  process.  If  it  occur,  pressure  or  the  actual  cautery  will  be 
found  the  best  means  to  arrest  it ;  and,  if  these  fail,  ligature  of  the  artery 
higher  up,  or  amputation  when  practicable,  might  be  required. 

The  parts  that  are  alread3’'  gangrenous  should  be  enveloped  in  lint 
soaked  in  solutions  of  carbolic  acid,  the  chlorides  of  zinc  or  lime,  or 


576 


MORTIFICATION,  OR  GANGRENE. 

ci'easote,  or  dusted  with  charcoal  powder.  No  poultices  should  be  ap¬ 
plied  if  the  sloughs  be  large,  heat  and  moisture  hastening  their  decom¬ 
position  ;  but  if  they  be  small,  yeast,  carrot,  or  charcoal  poultices  may  be 
advantageously  applied. 

Parts  that  are  quite  dead,  but  that  do  not  readily  separate,  such  as 
tendons,  ligaments,  and  bones,  may  be  cut  through  with  scissors,  pliers, 
or  saws,  and  thus  many  weeks  or  months  saved  in  their  separation.  It 
may  occasionally  be  necessary  in  doing  this  to  encroach  on  the  living 
tissues ;  this  should  be  done  as  carefully  and  as  sparingly  as  possible, 
for  reasons  already  stated.  They  do  not  bleed  much,  owing  to  their 
infiltration  with  lymph. 

The  line  of  separation  should  be  dressed  with  water-dressing,  or  with 
some  mild  detergent  lotion  or  ointment,  in  order  to  keep  the  surface  clean 
and  free  from  absorption  of  gangrenous  matters.  If  sloughs  be  not 
readily  separated,  the  balsam  of  Peru,  either  pure  or  diluted  with  yolk 
of  egg  or  very  dilute  nitric  acid,  and  opiate  lotions,  are  the  most  useful 
applications.  After  the  separation  of  the  sloughs,  the  ulcerated  surface 
must  be  treated  on  general  principles. 

The  Treatment  of  Senile  Gangrene,  presenting  some  peculiari¬ 
ties,  requires  a  few  words  to  be  specially  devoted  to  it. 

Constitutional  Treatment. — By  some  Surgeons  this  disease  has  been 
treated  on  a  strictly  anti-inflammatory  plan,  on  the  supposition  that  the 
obstruction  of  the  arteries  is  caused  by  the  inflammation  of  their  coats. 
This,  however  true  it  maj'-  be  in  some  of  the  forms  of  “spontaneous  gan¬ 
grene”  arising  from  acute  obstructive  arteritis  in  young  subjects,  is  cer¬ 
tainly  an  erroneous  doctrine  in  the  great  majority  of  cases  of  dry  gan¬ 
grene  occurring  as  the  result  of  senile  changes  in  the  lower  extremities 
of  aged  persons  ;  and,  though  inflammation  may  occasional!}^  affect  the 
calcified  coats  of  an  artery,  or  the  parts  supplied  by  such  a  diseased  ves¬ 
sel,  it  is  always  a  low  form  of  the  disease,  and  does  not  bear  depletion. 
Brodie  very  j  ustly  observes,  that  in  these  cases  the  local  precursory  inflam¬ 
mation  terminates  in  mortification, because  the  inflamed  part  cannot  obtain 
the  additional  supply  of  blood  that  it  requires  ;  hence,  if  blood  be  ab¬ 
stracted  from  the  system,  and  the  action  of  the  heart  weakened,  the  cause  of 
the  disease  will  only  be  aggravated.  But,  though  depletory  measures  are 
not  admissible,  w^e  must  guard  against  running  into  the  opposite  extreme, 
and  over-stimulating  patients  laboring  under  this  disease.  Senile  gan¬ 
grene  commonly  occurs  in  individuals  belonging  to  the  wealthier  classes 
of  society,  who  have  lived  high,  taken  insutficient  exercise,  and  conse¬ 
quently  induced  an  irritable,  plethoric,  but  enfeebled  state  of  system. 
In  many  cases  the  patients  are  of  a  gouty  habit,  and  occasionally  the 
inflammation  that  precedes  the  development  of  the  gangrene  appears  to 
be  of  this  nature.  In  this  condition  stimulants  and  the  more  powerful 
tonics  are  not  well  borne ;  they  heat  the  system,  accelerate  the  pulse,  and 
interfere  with  digestion.  As  Brodie  observes,  it  is  of  great  importance 
in  this  disease  to  attend  to  the  state  of  the  digestive  organs,  in  order 
that  nutrition  may  go  on,  and  that  blood  of  a  proper  quality  may  be 
made.  In  order  to  accomplish  this,  a  light  nourishing  diet,  partly  animal 
and  partly  vegetable,  should  be  given,  and  a'moderate  quantity  of  wine, 
beer,  or  brandy  allow^ed.  The  bowels  must  be  relieved  from  time  to  time 
by  a  rhubarb  draught  or  simple  aperient  pill.  Mercury  depresses  the 
system,  and  hence  it  should  not  be  used  as  an  aperient  in  any  form  in 
this  disease,  unless  the  state  of  the  liver  imperatively  require  it.  If  the 
digestion  become  impaired,  a  stomachic,  as  the  infusion  of  cascarilla 
or  the  compound  infusion  of  gentian  with  a  little  ammonia,  may  be 


AMPUTATION  IN  GANGRENE. 


577 


administered.  The  administration  of  opium  in  these  cases,  as  originally 
recommended  by  Pott,  has  received  the  sanction  of  almost  every  practical 
Surgeon.  Brodie’s  opinion  on  this  point  is  peculiarl}^  valuable  ;  he  says, 
“  If  I  am  not  greatly  mistaken,  the  result  of  a  particular  case  will  very 
much  depend  on  this — whether  opium  does  or  does  not  agree  with  the 
patient.’’  From  two  to  four  grains  of  opium  may  be  administered  in 
divided  doses  in  the  course  of  twent^'-four  hours ;  the  quantity  being- 
increased  as  the  sj’stem  becomes  accustomed  to  its  effects.  If,  however, 
it  disturb  the  stomach  and  occasion  headache,  notwithstanding  the  use 
of  aperients,  as  will  often  happen  when  there  is  febrile  disturbance  in 
persons  of  a  full  habit  of  body,  it  must  be  discontinued,  as  it  will  increase 
the  irritation  of  the  system.  The  pain  in  the  foot,  which  is  often  very 
severe  during  the  progress  of  the  disease,  usually  ceases  of  itself  when 
the  mortification  is  complete ;  and  before  this,  it  is  but  little  influenced 
by  any  sedatives,  whether  constitutionally  or  locally  applied.  With 
respect  to  the  comparative  advantages  of  the  depletory  and  stimulating 
plans  of  treatment  in  senile  gangrene,  I  think  it  may  fairly  be  stated 
that  neither  method  should  be  applied  exclusive!}’ ;  that  in  those  cases 
in  which  there  is  much  febrile  action,  in  which  the  tongue  is  loaded,  the 
pulse  quick,  and  the  skin  hot,  in  which  the  spread  of  the  gangrene  is 
preceded  by  a  red  angiy  blush,  with  much  pain  and  heat,  moderate  diet 
and  mild  tonics  will  be  most  useful ;  whilst,  on  the  other  hand,  when  it  is 
simply  a  shrivelling  of  the  toes  and  feet,  without  any  preceding  increased 
local  action,  or  febrile  constitutional  disturbance,  a  decided  tonic  or 
stimulating  plan  will  succeed  best. 

The  Local  Means  to  be  employed  in  senile  gangrene  are  simple.  It  is 
of  great  importance  to  keep  up  the  temperature  of  the  limb,  and  to 
equalize  its  circulation  as  much  as  possible ;  this  is  best  done  by  the 
application  of  cotton-wadding  or  of  carded  wool  in  thick  la3’ers  around 
the  foot  and  leg,  so  as  to  envelop  the  limb  completely  in  this  material, 
over  which  a  large  worsted  stocking  may  be  drawn,  or  a  silk  handker¬ 
chief  stitched.  This  dressing  need  not  be  removed  more  than  once  or 
twice  a  week,  unless  there  be  much  discharge  from  the  line  of  separation, 
when  it  must  be  changed  more  frequently ;  the  gangrened  part  itself 
should  be  covered  with  a  piece  of  lint  soaked  in  chlorinated  lotion.  When 
the  soft  parts  have  been  separated,  and  the  bones  of  the  foot  exposed, 
these  should  be  cut  across  by  cutting-pliers  or  a  small  saw,  and  the  sore 
that  results  dressed  in  the  ordinary  way  with  some  astringent  lotion  or 
slightly  stimulating  ointment.  The  balsam  of  Peru,  either  pure  or  diluted, 
with  an  equal  part  of  yolk  of  egg,  is  a  very  excellent  application  in  these 
cases.  In  the  event  of  recovery,  the  patient  must  be  careful  to  avoid 
exposure  to  cold,  and  to  keep  the  legs  warmly  clad  at  all  seasons  of  the 
year. 

Amputation  in  Gangrene. — The  question  of  Amputation  in  cases 
of  gangrene  of  the  limbs  is  of  great  importance  to  the  practical  Surgeon, 
and  is  one  on  certain  points  of  which  the  opinions  of  the  best  practi¬ 
tioners  still  vary.  At  first  sight  it  appears  rational  to  cut  off  a  limb 
that  is  dead,  disorganized,  and  offensive ;  and  with  propriety  this  may 
be  done  when  the  gangrene  is,  strictl}^  speaking,  a  local  affection,  as,  for 
instance,  the  result  of  a  severe  injury:  any  affection  of  the  constitution 
in  such  a  case  being  secondary  to  the  local  mischief,  and  dependent  on 
the  irritation  set  up  by  it,  and  on  the  depression  of  the  powers  of  life 
consequent  on  the  efforts  made  by  nature  to  rid  the  system  of  a  spoiled 
member.  But  when  the  constitutional  disease  is  the  primary  affection, 
and  when  the  gangrene  is  consecutive  to  and  dependent  upon  this,  it 
VOL.  I. — 37 


678 


MORTIFICATION,  OR  GANGRENE. 

would  clearly  be  useless  to  cut  off  the  mortified  part,  as  the  same  morbid 
action  might  and  would  be  set  up  in  the  stump  or  elsewhere.  Hence  the 
broad  question  of  amputation  in  cases  of  gangrene  turns  upon  the  fact 
of  the  mortification  being  local  or  constitutional  in  its  origin. 

When  the  gangrene  is  locals  we  usually  amputate  at  once ;  especially 
when  the  mortification  results  from  severe  injuries,  or  is  the  result  of  the 
wound  or  ligature  of  an  artery.  Here,  for  the  reasons  which  have  been 
given  (pp.  183,  269),  amputation  should  be  performed  as  soon  as  the 
gangrene  has  unequivocally  manifested  itself,  without  waiting  for  the 
line  of  demarcation.  The  result  of  amputation  for  traumatic  gangrene  is, 
on  the  whole,  very  unfavorable ;  the  patient  very  commonly  sinking  from 
a  recurrence  of  the  disease  in  the  stump,  or  from  the  constitutional  dis¬ 
turbance  that  had  previously  set  in.  Those  cases  are  especially  unfa¬ 
vorable  in  which  the  areolar  tissue  of  the  limb  is  much  infiltrated  and 
disorganized ;  the  affection  indeed  partaking  more  of  the  characters  of 
constitutional  disease,  with  some  forms  of  which  it  is  closely  associated. 

There  are  two  exceptions  to  the  rule  of  amputating  in  traumatic  and 
local  gangrene  before  the  occurrence  of  the  line  of  demarcation ;  viz., 
gangrene  from  frost-bite,  and  that  from  severe  burns.  In  these  injuries 
it  is  better  to  wait  for  the  formation  of  the  line  of  separation,  and  then 
to  fashion  the  stump  through  or  just  above  it  as  the  circumstances  of 
the  case  require. 

In  gangrene  from  constitutional  causes,  it  is  a  golden  rule  in  surgery 
never  to  amputate  until  the  line  of  separation  has  formed ;  for,  as  it  is 
impossible  in  these  cases  to  say  where  the  mortification  will  stop,  the 
amputation  might  be  done  either  too  high  or  not  high  enough ;  and,  in 
any  circumstances,  the  morbid  action  would  to  a  certainty  be  set  up  in 
the  stump.  It  is  not  even  sufficient  in  cases  of  this  kind  to  wait  until 
the  line  of  demarcation  has  formed  before  removing  the  limb ;  these 
spontaneous  or  constitutional  gangrenes  having  often  a  tendency  to 
remain  stationary  for  some  days,  and  then,  creeping  on,  to  overstep  the 
line  by  which  they  had  at  first  appeared  to  be  arrested.  Besides  this, 
the  local  disturbance  and  inflammation  set  up  by  the  amputation  might 
be  too  great  for  the  lessened  vitality  of  the  system  or  part,  and  might 
of  itself  occasion  a  recurrence  of  the  gangrene.  Hence  in  these  cases  it 


Fig.  210. 


Spontaneous  Amputation  in  Gangrene  of  Right  Foot  and  Left  Leg  from  Plastic  Arteritis. 

is  alwa3^s  well  to  wait  until  the  line  of  separation  has  ulcerated  so  deeply 
that  there  is  no  chance  of  the  gangrene  overleaping  this  barrier,  at  the 
same  time  that  means  are  taken,  by  the  administration  of  tonics,  nour¬ 
ishing  food,  &c.,  to  improve  the  patient’s  strength  and  fitness  for  the 
operation.  So  soon  as  this  has  been  done  in  a  satisfactory  manner,  and 


BED-SORES. 


579  > 


all  the  soft  parts,  except  the  ligaments,  have  been  ulcerated  through,  the 
mortified  part  should  be  separated  by  cutting  through  the  remaining 
osseous,  ligamentous,  or  tendinous  structures,  and  then  means  should 
be  taken  to  fashion  the  stump  that  has  been  formed  hy  nature.  In  some 
cases  this  will  be  sufficiently  regular  to  serve  every  useful  purpose  after 
it  has  cicatrized.  In  most  instances,  however,  the  stump  is  more  irregu¬ 
lar  and  unsightly,  of  which  the  accompanying  drawing  (Fig.  210)  is  a 
good  illustration ;  and  the  bones  protrude  to  such  an  extent,  or  the 
ulceration  has  affected  the  soft  parts  so  irregularlj^,  that  it  is’ necessary , 
in  order  to  give  the  patient  an  useful  limb,  to  amputate  through  the 
face  of  the  stump,  or  higher  up.  All  this  must  be  left  to  the  discretion 
of  the  Surgeon ;  but  no  procedures  of  this  kind  should  be  undertaken 
until  the  patient’s  strength  has  been  sufficiently  restored  to  bear  the 
operation. 

In  senile  gangrene  it  has  been  proposed  to  amputate  the  thigh  high 
up.  This  practice  has  been  successfully  adoj^ted  by  Garlike,  James,  of 
Exeter,  and  others,  and  certainly  appears  to  deserve  a  trial  in  all  cases 
in  which  the  health  is  otherwise  good  and  the  constitution  tolerably 
sound.  It  has  not  as  yet  been  adopted  in  a  sufficient  number  of  cases  to 
warrant  a  positive  opinion  on  its  merits  ;  but  it  would  appear  that,  for  it 
to  succeed,  the  amputation  should  be  done  high  up  in  the  thigh,  so  that 
there  ma}"  be  a  better  chance  of  meeting  with  a  healthy  condition  of  the 
vessels  and  good  vitalit}"  in  the  limb ;  the  operation  being  performed  on 
the  principle,  that  this  form  of  gangrene  is  dependent  on  local  disease 
obstructing  the  vessels  of  the  part,  and  not  always  on  constitutional 
causes. 


CHAPTER  XXXI. 

GANGRENOUS  DISEASES. 

BED-SORES. 

When  a  part  of  the  body  is  compressed  too  severely,  or  for  too  long 
a  time,  even  in  a  healthy  constitution,  it  loses  its  vitality,  and  a  local 
limited  slough  results ;  this  separates,  and  an  ulcer  is  left,  which  cica¬ 
trizes  in  the  usual  way.  But  in  certain  deranged  states  of  the  health, 
more  especiall}^  when  the  blood  is  vitiated,  and  the  constitutional  powers 
lowered,  as  during  fever,  or  when  the  heart  is  diseased  and  weakened  in 
power,  more  particularly  if  the  patient  be  old,  debilitated,  or  paralyzed, 
the  skin  covering  those  points  of  the  body  that  are  naturally  and  neces¬ 
sarily  pressed  upon  in  the  recumbent  position,  such  as  the  sacrum,  the 
trochanters,  the  elbows,  shoulders,  and  heels,  becomes  congested  and 
inflamed,  assuming  a  dull  reddish-brown  color,  and  speedily  becomes  ex¬ 
coriated  without  any  pain  being  felt  by  the  patient.  It  is  not  so  much 
the  actual  severity  of  the  pressure  that  occasions  a  bed-sore,  as  moderate 
long-continued  pressure  applied  to  a  part  congested  by  position  in  a 
patient  enfeebled  by  disease  or  want.  If  means  be  not  taken  to  improve 
the  patient’s  health  and  strength,  and  to  relieve  the  part  from  the  inju¬ 
rious  compression  to  which  it  is  subjected,  and  more  especially  if  it  be 
irritated  by  the  contact  of  feces  or  urine,  the  subcutaneous  areolar  tissue 
corresponding  to  the  inflamed  patch  will  become  widely  softened  and 


580 


GANGRENOUS  DISEASES. 


douglu",  being  conA’erted,  with  the  skin  covering  it,  into  a  tough  gra3’ish 
slough,  from  under  which  a  thin  ichorous  pus  exudes.  This  slough  may 
extend  by  a  process  of  undermining  of  the  integuments  covering  it ;  and 
on  its  separation  extensive  mischief  will  be  disclosed,  the  fascia  and 
tendons  being  exposed,  or  the  bones  laid  bare,  and  soon  becoming  rough¬ 
ened  and  carious.  In  some  cases,  even  the  inferior  aperture  of  the 
sj^inal  canal  ma}"  be  laid  open,  and  death  ma}’’  result  from  a  low  form  of 
arachnitis,  in  consequence  of  the  irritation  spreading  to  the  membranes 
of  the  cord.  In  other  cases,  the  patient  dies  worn  out  bj’  discharge  and 
irritation. 

Treatment. — This  is  in  a  great  measure  preventive.  When  a  patient 
is  likely  to  be  confined  to  bed  for  many  weeks,  especially  b}''  exhausting 
disease,  steps  should  be  taken,  by  proper  arrangement  of  the  pillows,  and 
b}’  the  use  of  the  water-bed  and  cushions,  to  prevent  pressure  from  being 
iujuriousl}'  exercised  upon  aii}^  one  part.  At  the  same  time,  cleanliness 
and  dr3’uess  should  be  carefull3"  provided  for  b3"  proper  nursing,  b3’  the 
use  of  a  draw-sheet,  and  furnishing  the  bedstead  with  the  necessar3^ 
arrangements  of  bedpan,  etc.  The  skin  on  the  exposed  parts  ma3'  be 
protected  b3’  the  application  of  collodion  or  soap-plaster  spread  upon 
wash-leather  or  amadou,  or  isinglass  or  felt ;  or,  what  is  better,  it  may 
be  strengthened  b3^  being  washed  with  spirits  of  wine,  either  pure  or  with 
two  grains  of  bichloride  of  mercuiy  dissolved  in  each  ounce. 

If  the  skin  have  become  chafed,  the  removal  of  pressure  is  imperative, 
and  the  abrasion  ma3"  be  washed  over  with  collodion ;  if  a  sore  have 
formed,  it  ma3'  be  dressed  with  the  balsam  of  Peru,  either  pure  or  diluted 
with  the  3’olk  of  egg,  spread  upon  lint.  In  these  cases  also  the  prone 
couch  ma3"  occasionall3^  be  advantageousl3'  substituted  for  the  ordinary 
bed  previousl3"  emplo3'ed.  When  sloughs  have  formed,  their  separation 
must  be  facilitated  133"  the  use  of  charcoal  or  chlorinated  poultices,  and 
the  ulcers  that  are  left  should  be  dressed  with  astringent  and  aromatic 
applications,  such  as  catechu,  tincture  of  nyrrh,  etc. ;  but  no  dressing 
that  the  Surgeon  can  appl3’' will  cause  these  ulcers  to  clean,  and  still  less 
to  heal,  unless  pressure  be  removed  and  the  patient’s  general  health 
improve,  and  then  they  will  speedil3’'  recover  under  the  most  simple 
treatment. 


SLOUGHING  PHAGEDH:NA. 

This  affection,  which  is  also  commonl3^  known  b3’  the  names  of  Hos¬ 
pital^  Contagious^  or  Pulpy  Gangrene^  is  characterized  by  a  rapidly 
destructive  and  spreading  ulcer,  covering  itself  as  it  extends  b3'  an  adhe¬ 
rent  slough,  and  attacking  open  sores  and  wounds.  It  is  rarel3"  met  with 
in  its  fullest  extent,  except  in  militaiy  practice;  the  accumulation  of  a 
large  number  of  wounded  w  ith  suppurating  sores  under  one  roof,  and  the 
want  of  the  necessaiy  cleanliness  and  attention  during  an  active  cam¬ 
paign,  disposing  to  it.  Overcrow’ding  of  a  hospital  is  the  most  fertile 
cause  of  this  disease,  as  also  of  eiysipelas  and  p3'eemia.  It  used  formerly 
to  desolate  the  civil  hospitals;  but,  thanks  to  the  sanitary  measures  now 
generall3'  adopted  in  these  institutions,  it  has  almost  disappeared  from 
them,  though  still  an  outbreak  of  it  occasionally  takes  place,  more  espe¬ 
cially  during  the  winter  or  earl3^  spring  months,  when,  in  consequence 
of  cold  winds,  the  windows  are  kept  shut  and  ventilation  is  thus  inter¬ 
fered  with. 

Local  Signs. — When  sloughing  phagedmna  invades  a  wound  that 
has  hitherto  been  perfectly  health3’,  the  surface  becomes  covered  with 


SLOUGHING  PHAGEDENA. 


581 


gray  soft  points  of  sloiigb,  which  rapidly  spread,  until  the  whole  of  the 
ulcer  is  affected.  At  the  same  time  the  sore  increases  rapidly  in  superficial 
extent,  and  commonly  in  depth  ;  the  surrounding  integument  becomes 
oedematous,  swollen,  and  of  a  livid  red  color ;  the  edges  of  the  ulcer  are 
everted,  sharp-cut  and  assume  a  circular  outline;  and  its  surface  is 
covered  with  a  thick  pulpy  grayish-green  tenacious  mass,  which  is  so 
firmly  adherent  that  it  cannot  be  wiped  off,  being  merely  moved  or 
swayed  to  and  fro  when  an  attempt  is  made  to  remove  it.  There  is 
usually  some  dirt}^  yellowish-green  or  brownish  discharge,  and  occa¬ 
sionally  some  bleeding ;  the  pain  is  of  a  severe  burning,  stinging,  and 
lancinating  character ;  and  the  foetor  from  the  surface  is  considerable. 
The  ravages  of  this  disease,  when  fully  developed,  are  very  extensive. 
The  soft  parts,  such  as  the  muscles,  areolar  tissue,  and  vessels,  are  trans¬ 
formed  into  a  gray  pulpy  mass,  and  the  bones  are  denuded  and  necrosed. 
The  larger  bloodvessels  resist  the  progress  of  the  disease  longer  than 
any  other  parts,  but  ma}-  at  last  be  exposed,  pulsating  at  the  bottom  of 
the  deep  and  foul  chasm.  There  is,  however,  little  risk  of  hemorrhage 
in  the  early  stages  :  but,  when  the  sloughs  are  separating,  an  arteiy  may 
give  way,  and  bleeding  to  a  dangerous  or  fatal  extent  ensue.  Hennen 
states  that  there  is  most  danger  of  this  about  the  eleventh  day.  When 
the  sloughs  are  thrown  off,  in  the  form  of  reddish-brown  or  gra3dsh- 
green,  viscid,  and  pulp^^  masses,  a  veiy  sensitive  granulating  surface  is 
left,  having  a  great  tendenc}’’  to  bleed,  and  to  be  again  invaded  by  the 
sloughing  action. 

Blackadder  has  described  an  ulcerated  form  of  this  affection,  in  which 
a  vesicle  containing  a  bloody  ichor  forms,  wdth  a  hot  stinging  pain  ;  this 
breaks,  leaving  a  circular  ulcer  of  about  the  size  of  a  split  pea.  The 
ulcer,  once  formed,  rapidlj’-  extends  by  sharp-cut  edges  into  the  surround¬ 
ing  integument. 

On  the  two  occasions  in  which  I  have  had,  in  former  ^^ears,  the  oppor¬ 
tunity  of  witnessing  outbreaks  of  this  disease  in  University  College 
Hospital,  the  surface  of  the  w^ounds  affected  became  rapidl}'’  covered 
with  a  yellowish-gray  pultaceous  slough.  In  some  cases  there  was 
hemorrhage  ;  but  most  commonly  a  small  quantity  of  fetid  discharge 
onl3"  was  poured  out,  the  edges  of  the  sore  became  sharp-cut  and  defined, 
and  the  ulceration  extended  further  in  the  skin  b^"  an  eighth  or  a  quarter 
of  an  inch  than  in  the  subjacent  areolar  tissue.  In  most  instances  the 
disease  was  confined  to  the  skin  and  areolar  tissue,  exposing  but  not 
usually  invading  the  muscles  and  bones,  though  in  some  cases  these  were 
affected.  The  ulcers  were  somewhat  circular,  and  were  surrounded  by 

dusky  inflamed  areolae  of  some  width.  When  once  the  morbid  action 

%/ 

was  stopped,  they  cleaned  rapidlj",  throwing  out  large  vascular  granu¬ 
lations. 

Constitutional  Symptoms. — These  are  inflammatoiy  in  the  first 
instance,  with  a  tendency  to  asthenic  and  irritative  fever  as  the  disease 
advances.  In  the  majority  of  cases  the,y  follow  the  local  invasion  of  the 
sore  :  Blackadder,  Hollo,  Delpech,  and  Wellbank  have  all  found  this  to 
be  the  case,  and  in  the  instances  at  Universit3"  College  Hospital  it  cer¬ 
tainly^  was  so.  Hennen  and  Thomson,  on  the  other  hand,  state  that  the 
constitutional  syunptoms  precede  the  local.  This  decrepancy  of  obser¬ 
vation  may  be  explained  by  the  difference  in  the  cause  of  the  disease ; 
if  it  occur  from  contagion,  the  constitutional  symptoms  will  be  secon¬ 
dary  ;  if  from  causes  acting  on  the  general  system,  they  may  probably^ 
be  primaiy. 

All  wounds  and  sores  are  liable  to  be  attacked  in  this  way,  but  the 


582 


GANGRENOUS  DISEASES. 


disease  most  frequently  affects  those  that  are  of  recent  origin  ;  the  more 
chronic  affections,  and  those  that  are  specific,  veiy  usually  escape. 

Causes. — Overcrowding  of  patients,  more  particularly  those  with 
suppurating  wounds,  in  the  same  ■ward  or  room,  is,  I  believe,  the  great 
occasioning  cause  of  hospital  gangrene  and  sloughing  phagedsena. 
I  believe  that  in  this  wa}^  the  disease  may  at  any  time  be  produced. 
The  last  outbreak  that  occurred  at  University  College  Hospital  was 
clearl}"  referable  to  that  cause,  and  ta  that  cause  onlj^  In  one  of 
m}’  wards,  which  is  intended  to  contain  15  or  16  patients  only,  owing  to 
accidental  and  unavoidable  circumstances,  21  patients  were  admitted, 
and  slept  for  one  night,  many  of  them  having  suppurating  wounds.  The 
result  was  an, outbreak  of  hospital  gangrene,  which  spread  through  the 
Institution,  and  was  most  serious  and  persistent.  Xext  to  overcrowd¬ 
ing,  I  believe  that  the  most  fertile  causes  of  this  disease  are  want  of 
cleanliness  and  ventilation,  and  unchanged  dressings.  The  accumula¬ 
tion,  indeed,  of  animal  exhalations  from  the  sick  and  wounded,  is  a 
course  of  various  forms  of  low  fever  of  allied  diseases ;  and  hospital 
gangrene,  when  it  occurs  in  these  circumstances,  may  be  taken  as  evi¬ 
dence  of  the  infringement  of  the  sanitary  laws  in  accordance  with  which 
the  arrangements  of  an  hospital  should  be  regulated.  But,  though  it 
commonly  has  its  origin  in  this  way,  especially  in  the  crowding  of  mili- 
taiy  hospitals  after  a  hard-fought  action,  it  is  met  with  out  of  hospitals 
Well-marked  cases  of  this  affection,  some  of  a  very  severe  character, 
have  at  times  occurred  amongst  the  out-patients  of  Universit}’’  College 
Hospital.  In  these  cases,  as  in  maiy^  others,  it  is  probable  that  the  dis¬ 
ease  was  occasioned  by  the  neglect  of  lygienic  conditions,  in  the  close 
and  ill-ventilated  houses  of  the  poor,  aided  possibly  by  some  atmos¬ 
pheric  or  epidemic  influence ;  influenza,  eiysipelas,  and  phlebitis  being 
also  very  prevalent.  This  had  been  observed  at  the  time  of  the  first 
occurrence  of  the  disease  at  our  Hospital,  in  1841 ;  and  I  think  it  is 
difficult  not  to  recognize  a  similarity  of  cause  in  these  different  affec¬ 
tions.  When  once  it  has  occurred,  it  ma}-  readily  spread  by  contagion, 
though  there  is  no  evidence  to  show  that  it  is  infectious.  Hence  the 
necessit}^  of  preventing  its  spread  through  the  incautious  use  of  sponges 
by  nurses  or  attendants,  and  of  destro3ung  the  dressings  used  bj"  the 
patients. 

Treatment. — The  first  point  to  attend  to  is  to  prevent  the  extension 
of  the  disease  to  patients  who  are  not  as  j^'et  affected.  This  ma^^  be 
clone  b}^  separating  those  who  have  been  seized  with  it  from  the  health}^, 
b}'  preventing  overcrowding  of  the  hospitals,  ventilating  the  wards, 
washing  the  floors  with  a  solution  of  the  chlorides,  whitening  the  walls, 
and  fumigating  the  apartment  with  chlorine  gas. 

Local  Treoiinent. — The  extension  of  the  slough  must  be  stopped  b}’’ 
the  free  application  of  fuming  nitric  acid,  or  of  the  actual  cauteiy,  to 
the  edges  and  surface  of  the  ulcer.  I  have  used  both  these  agents,  but 
prefer  the  nitric  acid,  if  strong  and  freeh’’  applied,  the  sides  and  edges 
being  well  sponged  with  it.  The  actual  cauteiy  is,  however,  veiy  useful 
in  those  cases  in  which  the  surface  to  be  destroyecl  is  very  extensive,  or 
if  there  be  a  tendenc}'  to  hemorrhage.  Should  it  not  reach  the  deeper 
portions  of  the  sore,  nitric  acid  ma^'  be  freely  sponged  into  them.  It  is 
important  to  bear  in  mind  that  these  escharotic  applications  should  be 
carried  cleepl}",  so  as  to  affect  the  living  structures  Ijing  beneath  the 
tenacious  graj"  P^^llW  slough,  and  that  their  action  be  not  fruitlessly 
expended  upon  charring  this,  which  is  already’'  disorganized.  Hence, 
before  the  application  of  the  caustic,  the  soft  pulpy  slough  should  be 


TREATMENT  OF  SLOUGHING  PHAGEDENA. 


583 


scraped  off  with  a  spatula.  After  the  cauterization  a  strip  of  lint, 
soaked  in  a  strong  solution  of  the  watery  extract  of  opium,  should  be 
laid  around  the  margin  of  the  ulcer,  so  as  to  cover  the  surrounding 
areola ;  and  the  separation  of  the  sloughs  must  be  encouraged  by  the 
continued  application  of  charcoal,  yeast,  or  chlorinated  poultices.  When 
they  have  separated,  and  the  surface  of  the  sore  has  cleaned,  it  ma}’’  be 
dressed  with  a  lotion  composed  of  one  grain  of  the  sulphate  of  copper 
and  five  of  the  wateiy  extract  of  opium  to  the  ounce  of  water.  The 
granulations,  which  are  very  luxuriant  and  vascular,  will  skin  over  with 
great  rapidity  ;  and  the  cicatrix,  like  that  of  an  ordinary  burn,  will  con¬ 
tract  very  firmly. 

Should  arterial  hemorrhage  occur,  it  may  be  arrested  by  the  applica¬ 
tion  of  a  ligature  to  the  bleeding  point ;  but  if  this  do  not  hold,  as  will 
probably  be  the  case  from  the  softened  state  of  the  tissues,  the  per- 
chloride  of  iron  or  the  actual  cautery  must  be  applied  ;  or  the  limb  must 
be  removed  if  all  other  means  fail. 

In  some  cases,  though  the  sloughing  action  is  checked  at  one  part  of 
the  surface,  it  has  a  tendency  to  spread  at  another.  When  this  is  the 
case,  it  may  be  necessary  to  apply  the  caustic  or  cautery  repeatedl3^  In 
other  instances,  the  sloughing  action  cannot  be  stopped,  but  opens  large 
arteries,  and  destroys  the  greater  part  of  the  soft  tissues  of  a  limb ;  and 
then  it  may  be  a  question  whether  amj^utation  should  be  performed 
during  the  spread  of  the  disease,  or  the  patient  left  to  die  of  hemor¬ 
rhage  or  exhaustion.  Such  a  contingency  is  not  of  common  occurrence  ; 
yet  it  may  happen  and  the  operation  be  successful,  as  appears  from  the 
following  case,  though  there  would  necessarily  be  great  danger  of  a 
recurrence  of  the  disease  in  the  stump.  The  wife  of  a  butcher  applied 
at  the  Hospital,  with  a  slight  wound  of  the  forearm,  inflicted  by  a  foul 
hook.  It  was  dressed  in  the  ordinary  way,  but  in  the  course  of  a  few 
da^’S  she  returned  with  extensive  sloughing  phagedaena  of  the  part. 
She  was  immediately  admitted,  and  the  disease  was  arrested  by  the 
energetic  employment  of  the  local  treatment  above  described ;  not,  how¬ 
ever,  until  after  considerable  destruction  of  the  tissues  on  the  inside  of 
the  forearm  had  taken  place.  She  left  the  Hospital  before  the  wound 
was  completely"  cicatrized,  and  returned  in  a  few  days  with  a  fresh  attack 
of  the  disease,  more  extensive  and  severe  than  the  first,  wdiich  could  not 
be  permanently^  stopped,  either  by  the  actual  cautery  or  by  nitric  acid. 
The  radial  artery  was  opened  and  required  ligature,  and  the  whole  of 
the  soft  parts,  from  the  wrist  to  the  elbow,  were  totally  disorganized, 
and  the  bones  exposed.  There  was  now  very  severe  constitutional  irri¬ 
tation,  and  the  case  was  evidently^'  fast  hastening  to  a  fatal  termination. 
In  these  circumstances  I  amputated  the  arm  midway  between  the 
shoulder  and  elbow ;  and,  notwithstanding  that  the  local  disease  was 
progressing  at  the  time  of  the  operation,  and  that  great  constitutional 
disturbance  existed,  the  patient  having  a  pulse  of  160  to  170,  at  which 
it  continued  for  more  than  a  fortnight,  she  made  a  good  recovery ;  to 
which  the  free  administration  of  quinine  and  stimulants  greatly  con¬ 
tributed. 

The  Constitutional  Treatment  must  have  for  its  object  the  removal  of 
the  combined  state  of  debility  and  irritation  in  which  we  find  the  patient. 
The  bowels  should  be  opened,  if  necessary,  by  warm  aperients  ;  as  nour¬ 
ishing  a  diet  as  the  patient  will  take,  with  a  liberal  supply  of  stimulants, 
should  be  ordered ;  and  these  may  be  increased  by  the  addition  of  the 
brandy-and-egg  mixture,  or  of  ammonia,  in  proportion  as  depression 
comes  on.  At  the  same  time  I  have  found  great  advantage  from  the 


584 


GANGRENOUS  DISEASES. 


administration  of  a  mixture  of  carbonate  of  ammonia,  gr.  v. ;  chlorate  of 
potass,  ;  compound  tincture  of  bark,  3j ;  decoction  of  bark,  ^iss,  every 
four  or  six  hours ;  or,  if  the  patient  will  bear  it,  from  five  to  seven 
grains  of  the  sulphate  of  quinine  every  four  or  six  hours,  with  a  full 
dose  of  opium  at  bedtime,  or  more  frequently  if  there  be  much  pain  and 
irritation. 


GANGRENOUS  STOMATITIS,  OR  CANCRUM  ORIS. 

A  peculiar  phagedaenic  ulceration,  closely  resembling  hospital  gan¬ 
grene,  is  occasionally  met  with  in  the  mouths  of  ill-fed  children  living  in 
low  and  damp  situations,  most  commonly  occurring  between  the  second 
and  sixth  or  eighth  3^ears,  but  more  especially  about  the  period  of  the 
second  dentition. 

In  its  mildest  form  this  aflection  presents  itself  as  small,  deep,  and 
foul  gra3dsh  ulcers,  on  the  inside  of  the  lips  or  cheeks,  attended  with  a 
red  spong3"  condition  of  the  gums  and  much  foetor  of  the  breath.  Good 
food  and  air,  with  nourishing  diet,  the  administration  of  bark,  with  the 
chlorate  of  potass,  and  the  use  of  chlorinated  lotions,  with  the  honey  of 
borax,  will  soon  bring  about  a  cure.  The  Spanish  snuff  {Sabilla)  ap¬ 
plied  to  the  sore  mouth,  or  placed  in  a  small  cambric  bag  on  the  tongue, 
has  a  very  good  effect  in  cleansing  these  sores,  and  especially  in  soothing 
irritation. 

Signs  of  Canerum  Oris. — The  more  severe  form  of  the  affection, 
the  true  Canerum  Oris,  commonly  occurs  during  convalescence  from 
some  of  the  eruptive  diseases  of  childhood,  or  after  the  incautious  ad¬ 
ministration  of  mercury  during  a  weak  state  of  the  S3^stem.  One  of  the 
cheeks  becomes  swollen,  brawn3^,  tense,  and  shining,  being  excessively 
hard,  and  presenting  a  red  patch  in  its  centre.  In  consequence  of  this 
swelling,  it  is  often  difficult  to  open  the  mouth ;  but  if  the  Surgeon  can 
gain  a  view  of  its  inside,  he  will  see  a  deep  and  excavated  foul  ulcer 
opposite  to  the  centre  of  the  external  swelling,  covered  with  a  brown 
pulp3"  slough.  The  gums  are  turgid,  dark  and  ulcerated  ;  the  saliva  is 
mixed  with  putrescent  matters ;  and,  as  the  ulceration  in  the  mouth  ex¬ 
tends,  the  swelling  sloughs,  and  a  large,  dark,  circular  gangrenous 
cavit3^  forms  in  the  cheek,  opening  through  into  the  mouth.  During  all 
this  time  the  child  suffers  little,  but,  as  the  disease  advances,  it  com- 
moul3^  becomes  drows3^,  and  at  last  dies  comatose.  When  full3^  devel¬ 
oped,  this  affection  is  most  fatal.  Rilliet  and  Barthez  state  that  not 
more  than  one  in  twent3’'  cases  recovers. 

Treatment. — The  treatment  is  that  of  hospital  gangrene.  The 
sloughing  mass  should  be  deepl3"  cauterized  with  nitric  acid,  but  not 
with  the  actual  cauteiy,  lest  the  cheek  be  destroyed  ;  the  mouth  should 
be  S3'ringed  with  the  dilute  solution  of  the  chlorides ;  and  the  S3’stem 
supported  with  beef-tea,  wine,  and  ammonia,  in  doses  proportioned  to 
the  age  of  the  child.  After  the  cure  of  the  disease,  the  cheek  may  be 
deeply  cicatrized,  contracted,  and  rigid,  much  in  the  same  way  as  after 
a  burn,  requiring  possibl3’'  some  plastic  operation  in  order  to  enable  the 
child  to  open  its  mouth  properl3^ 

BOILS. 

A  Boil  is  a  hard  circumscribed  tumor  of  a  violet  or  purplish-red  color, 
fiattened,  though  somewhat  conical,  suppurating  slowl3^  and  imperfectl3^, 
and  alwa3"s  containing  a  small  conical  central  slough  of  areolar  tissue 


TKEATMENT  OF  BOILS. 


585 


called  a  core.  It  consists  of  an  inflammation  of  the  subcutaneous  areolar 
tissue  and  of  the  under  surface  of  the  true  skin.  The  tension  and  hard¬ 
ness  accompan3dng  this  affection  render  it  extremely’’  painful  and  anno}"- 
ing.  It  is  most  commonl^^  seated  in  the  thick  skin  of  the  back,  the  neck, 
or  the  nates. 

Causes. — Boils  most  frequently  occur  in  young  people,  but  are 
common  enough  at  all  ages,  and  are  usually  seen  in  very  plethoric  or 
in  very  enfeebled  constitutions,  often  following  some  of  the  more  severe 
febrile  diseases,  and  attending  convalescence  from  them.  In  other  cases, 
the  S3’'stem  appears  to  have  fallen  into  a  cachectic  state,  often  without 
an3'  evident  cause,  and  this  terminates  b3^  a  critical  eruption  of  boils. 
A  sudden  change  in  the  habits  of  life,  as  from  sedentary  to  active  pur¬ 
suits,  a  course  of  sea-bathing,  etc.,  will  also  occasion  them.  They  are 
commonly  met  with  in  the  spring  of  the  3^eai\  but  ma3'  occur  at  all 
seasons,  and  are  occasionally  epidemic.  When  once  they  take  place 
the3"  are  often  extremely  tedious,  crop  after  crop  continuing  to  be 
evolved.  In  man3^  cases  they  must  be  looked  upon  as  salutaiy,  as  being 
the  means  adopted  by  nature  to  rid  the  patient  of  morbid  matters  that 
irritate  the  constitution,  and  which  might,  if  retained,  produce  disease 
in  it.  Hence,  after  an  outbreak  of  boils,  the  health  often  greatly  im¬ 
proves. 

Treatment. — The  Constitutional  Condition.,  on  which  the  disease  is 
dependent,  requires  to  be  carefully  attended  to.  No  one  remed3^  is  capa¬ 
ble  of  curing  boils.  The  disease  is  the  result,  in  some  cases,  of  fault  or 
defect  in  nutrition ;  and  the  gradual  modification  and  improvement  of 
those  processes  that  are  subservient  to  it  are  necessaiy  before  the  local 
eruptive  affection  will  cease  to  appear.  In  other  instances,  it  appears  to  be 
due  to  w’ant  of  proper  elimination  of  effete  materials.  Hence  less  is  often 
to  be  expected  from  medicines  in  these  cases,  than  from  the  general  regu¬ 
lation  of  the  h3'gienic  condition  of  the  patient.  Xature  will  do  more  for 
his  recover3^  than  art ;  and  the  utmost  that  the  practitioner  can  do  is  to 
administer  such  remedies  as  wdll  assist  in  the  improvement  of  the  consti¬ 
tutional  condition.  If  he  be  debilitated  and  cachectic,  iron,  quinine,  sar¬ 
saparilla,  and  cod-liver  oil ;  if  he  be  plethoric,  and  his  S3^stem  loaded,  pur¬ 
gatives,  salines,  and  liquor  potassae  will  be  appropriate.  In  the  one  case 
an  abundant  nourishing. diet,  in  the  other  case  a  spare  and  simple  one, 
with  avoidance  of  stimulants,  will  be  required.  In  some  cases,  empirical 
means  are  of  service.  Thus,  when  the  disease  is  associated  with  pom- 
phol3^x,  or  preceded  by  painful  vesicles,  arsenic  ma3’  be  of  benefit.  In 
other  instances,  3’east  or  charcoal  has  been  advantageously  given. 

The  Local  Treatment  of  boils  is  simple.  When  the3"  are  forming,  the 
most  useful  dressing  is  a  warm  spirit  lotion  kept  applied  with  lint  and 
oiled  silk ;  as  suppuration  comes  on,  a  linseed-meal  poultice,  either  simple 
or  made  with  port  wine,  may  be  advantageously  applied.  Most  com- 
monl3^  the  boils  ma3^  be  allowed  to  break,  wdien  the3'  discharge  a  thick 
pus,  together  wdth  the  central  core,  thus  leaving  a  small  cavity  in  and 
under  the  skin,  which,  however,  soon  fills  up.  The  Surgeon  may  in  some 
cases  find  it  necessary  to  open  them  by  a  crucial  incision  wdien  the3’  are 
large,  and  do  not  appear  disjDOsed  to  break  of  themselves.  When  the 
boil  commences  as  a  small  irritable  pustule,  it  may  occasionall3^  be  kept 
back  b3"  touching  the  point  of  this  with  nitrate  of  silver,  or  wdth  a 
saturated  solution  of  bichloride  of  merciuy. 


586 


GANGRENOUS  DISEASES. 


CARBUNCLE. 

A  Carbuncle  consists  essentially  of  a  circumscribed  and  limited  inflam¬ 
mation  of  the  subcutaneous  areolar  tissue,  rapidly  running  into  suppu¬ 
ration  and  slough.  The  rapid  formation  of  pulpy  gra3dsh  or  ash-colored 
sloughs  of  the  areolar  tissue  is  characteristic  of  the  disease,  Tvhether 
resulting  from  the  specific  nature  of  the  inflammation,  or,  more  probably, 
from  the  strangulation  of  the  part  by  the  accumulation  of  serum  and 
blood,  consequent  on  violent  inflammatory  action  in  parts  the  vitality  of 
which  has  been  materiall}"  lowered  by  constitutional  depressing  causes. 

Signs. — A  carbuncle  usually  begins  as  a  small  pointed  vesicle  situated 
on  a  hard  base  of  a  dusky  red  color.  There  is  generally  from  the  first  a 
hot,  burning,  stinging,  heavy,  or  throbbing  pain  in  the  part,  out  of  pro¬ 
portion  to  the  apparent  gravity  of  the  disease.  The  contents  of  the 
vesicle  speedily  become  puriform,  and  are  shed.  The  inflamed  base  then 
rapidly  enlarges  as  a  flat,  painful,  hard,  but  somewhat  doughy,  circum¬ 
scribed  swelling  of  the  integuments  and  subjacent  areolar  tissue.  The 
swelling  is  of  a  dusky  red  hue,  slightly  elevated,  but  never  loses  its 
flattened  circular  shape  ;  as  it  increases  in  size,  the  skin  covering  it 
assumes  a  purple  or  brownish-red  tint,  becomes  undermined,  and  gives 
way  at  several  points,  forming  openings  through  which  ash-gray  or 
straw-colored  sloughs  appear,  and  from  which  an  unhealthy  purulent 
discharge  scantil}^  issues.  The  size  of  the  swelling  varies  from  one  to 
six  inches  in  diameter ;  most  commonl}^  it  is  about  two  inches  across. 
Carbuncles  are  generally  met  with  on  the  posterior  part  of  the  trunk, 
more  especiall}^  about  the  shoulders  and  the  nape  of  the  neck ;  being 
rarely  seen  anteriorly,  or  on  the  extremities.  I  have,  however,  had  to 
treat  veiy  large  carbuncles  on  the  abdomen,  and  have  met  with  them  on 
the  shin,  forearm,  forehead,  lips,  and  cheeks. 

The  Constitutional  Disturbance  attending  this  disease  is  always  of 
the  sthenic  type ;  the  complexion  is  often  peculiarly  sallow  or  j^ellow,  the 
pulse  feeble,  and  the  tongue  loaded ;  and  if  the  tumor  be  large,  or  be 
seated  on  the  head,  death  may  take  place,  the  patient  sinking  into  a 
typhoid  state. 

Causes. — A  carbuncle  usually  arises  without  any  assignable  local 
exciting  cause ;  but  in  some  cases  it  is  evidently'  directly  occasioned  by 
the  introduction  of  some  poisonous  matter  into  a  puncture  in  the  skin  or 
a  hair  follicle.  In  all  cases  it  is  associated  with  and  dependent  upon  a 
disordered,  usually  a  low,  state  of  the  constitution.  Any  condition  that 
lowers  the  powers  of  the  system  will  predispose  to,  and  may  at  last  occa¬ 
sion,  carbuncle.  Habitually  bad  and  insufficient  food,  the  exhaustion 
induced  by  chronic  wasting  diseases,  as  diabetes,  albuminuria,  &c.,  or 
the  debility  resulting  from  acute  febrile  diseases — more  particularly 
t^q^hus — may  all  occasion  it.  Carbuncles  are  more  common  in  the  old 
than  in  the  j^oung,  and  in  men  than  in  women. 

Diagnosis. — Carbuncle  resembles  boil  in  many  points,  yci  differs  in 
its  greater  size,  the  dusk^'  red  of  the  inflamed  integument,  in  its  broad 
flat  character,  and  in  the  large  quantity  of  contained  slough  in  proportion 
to  the  small  amount  of  purulent  discharge,  as  well  as  in  the  conditions 
in  which  it  generally’"  occurs.  It  also  differs  from  a  boil  in  its  tendency 
to  spread.  A  boil  “  comes  to  a  head,”  bursts,  and  discharges  pus  and 
slough ;  a  carbuncle  will  be  discharging  and  sloughing  at  one  part, 
w'hilst  it  spreads,  hard  and  brawn^q  at  another. 

The  Prognosis  in  carbuncle  will  depend  on  the  size  of  the  swelling, 
on  its  situation,  and  on  the  state  of  the  patient’s  constitution,  more 


587 


TEEATMEXT  OF  CAEBUXCLE. 

particularly  on  that  of  bis  kidneys.  The  most  dangerous  carbuncles  are 
those  that  are  large,  and  situated  or  encroaching  on  the  scalp ;  in  fact, 
the  more  this  structure  is  involved  the  greater  the  danger.  If  the  con¬ 
stitution  be  good,  even  these  may  be  recovered  from;  but  if  the  kidneys 
be  unsound,  or  if  there  be  chronic  saccharine  diabetes,  the  progress  of 
the  disease  cannot  readily  be  checked,  and  the  patient  will  usually  sink. 

Treatment. — The  Constitutional  Treatment  must  be  conducted  on 
the  general  principles  that  guide  us  in  the  management  of  low  and 
sloughing  inflammations.  After  the  bowels  have  been  cleared  out,  the 
patient  should  be  put  on  ammonia  and  bark  if  much  depressed,  or  else 
the  mineral  acids  and  quinine.  The  latter  in  large  doses,  as  much  as 
five  grains  every  four  hours,  is  often  of  great  service.  Our  great  reliance 
in  the  more  severe  forms  of  the  disease  is,  however,  in  the  free  adminis¬ 
tration  of  dietetic  stimulants  and  2:ood  nourishment.  The  best  medicine 
in  such  cases  is  undoubtedl}"  port  wine  or  porter,  given  as  freely"  as  the 
patient  can  take  it.  The  mode  of  employment  of  stimulants  is  of  great 
importance  in  these  cases.  As  a  general  rule,  that  stimulant  will  best 
agree  to  which  the  patient  is  accustomed  during  health.  Beer  and  wine 
should  not  be  given  together,  but  either  will  go  well  with  brandy.  In 
addition  to  stimulants,  good  and  abundant  nourishment  should  be  given; 
meat,  if  the  patient  can  digest  it ;  if  not,  soups,  such  as  strong  beef  tea, 
essence  of  meat,  or  turtle-soup.  The  brandy-and-egg  mixture  is  also 
especially  serviceable. 

Local  Treatment. — In  the  very  early  stage,  when  the  disease  appears 
as  a  small,  angry,  pointed  vesicle  situated  on  a  hard  brawny  base,  its 
further  progress  may  often  be  completely  arrested  by  opening  the  vesi¬ 
cle,  and  rubbing  its  interior  with  a  pointed  stick  of  potassa  cum  calce  or 
nitrate  of  silver.  If  the  carbuncle  have  attained  a  somewhat  larger  size, 
though  still  small,  the  wisest  plan  is  to  cover  it  with  a  a  piece  of  soap- 
plaster  spread  on  leather,  having  a  hole  cut  in  the  centre,  through  which 
the  pus  and  sloughy  matters  ma}'  be  discharged.  Beyond  this,  nothing 
will  be  required.  When  larger,  it  should  be  poulticed.  In  these  cases 
the  question  will  arise  whether  it  should  be  incised  or  not;  and,  if 
incised,  in  wdiat  way  the  operation  should  be  practised.  Some  Surgeons 
uniformly  adopt  incisions  ;  others,  with  equal  constanc}^,  reject  them. 
I  think  that  the  exclusive  adoption  of  either  method  is  erroneous,  and 
that  the  most  successful  treatment  consists  in  allowing  the  question  of 
early  incision  to  be  determined  by  the  amount  of  tension  existing  in  and 
around  the  carbuncle.  Should  the  parts  be  soft,  relaxed,  and  compara¬ 
tively  painless,  no  advantage  can  result  from  incision;  but, on  the  other 
hand,  if  the  tension  be  considerable,  the  agon}-  great,  and  the  constitu¬ 
tional  disturbance  dependent  on  both  proportionate!}"  intense,  nothing 
gives  such  immediate  relief,  local  and  constitutional,  as  earl}"  and  free 
incision.  This  may  be  done  in  two  ways ;  either  subcutaneously,  by 
entering  a  long  bistoury  at  one  side  of  the  carbuncle,  and  making  two 
or  three  subcutaneous  sweeps  through  the  inflamed  tissues  at  different 
planes  in  depth ;  or  by  a  free  crucial  cut,  carried  fairly  through  the  dis¬ 
eased  parts  into  the  healthy  tissues  beyond  them.  By  either  method 
the  constitutional  disturbance  accompanying  and  resulting  from  the  ex¬ 
treme  tension  is  at  once  removed,  the  local  progress  of  the  disease  is 
checked,  and  extension  of  sloughing  by  strangulation  of  the  tissues  is 
prevented.  Should  incision  of  the  carbuncle  not  have  been  performed 
early,  it  may  become  necessary  at  a  later  period,  in  order  to  prevent 
the  confinement  of  the  pus  and  slough.  Poultices  are  now  to  be  applied  ; 
these  may  be  simply  of  linseed  meal  and  water,  or  they  may  be  made 


588 


ERYSIPELAS. 


more  stimulating  by  the  addition  of  port  wine,  5’east,  or  beer-grounds. 
As  the  sloughs  loosen,  they  should  be  separated ;  and  the  granulating  sur¬ 
face  which  is  left,  and  which  will  usuall^^  be  found  to  be  sluggish  in  its 
action,  should  be  dressed  with  some  of  the  more  stimulating  ointments, 
such  as  those  of  elemi,  resin,  or  balsam  of  Peru.  The  ulcer,  though 
large,  will  when  thus  treated  cicatrize  rapidly,  and  will  leave  but  a  small 
scar. 


CHAPTER  XXXII. 

ERYSIPELAS. 

Erysipelas  so  frequently  and  seriously  complicates  most  other  surgical 
diseases  and  injuries,  that  its  study  is  of  the  utmost  importance  to  the 
practical  Surgeon.  It  usually  manifests  itself  as  a  peculiar  and  distinct 
form  of  inflammation,  having  certain  special  characters  which  distinguish 
it  from  the  ordinary  inflammation  already  described.  Eiysipelas,  or,  as 
it  may  be  termed,  the  Erysipelatous  Inflammation^  including  all  those 
varieties  of  this  condition  that  are  usually  spoken  of  as  “  diffuse  fl  has  a 
remarkable  tendency  to  spread  itself  with  great  rapidity  by  continuit}" 
of  surface,  to  change  its  seat,  and  not  to  be  limited  by  any  adhesive 
action.  It  may  extend  itself  over  any  continuous  surface  ;  the  skin,  the 
areolar  tissue,  the  mucous  and  serous  membranes,  and  the  lining  mem¬ 
brane  of  arteries,  veins,  and  Ij^mphatics,  are  all  liable  to  be  affected. 
Hence,  to  describe  it  merely  as  a  cutaneous  disease,  as  has  often  been 
done,  is  in  the  highest  degree  incorrect  and  unphilosophical,  and  evinces 
a  very  limited  acquaintance  with  its  true  nature.  It  simply  aflfects  the 
skin  more  frequentlj^  than  other  membranous  surfaces,  because  the  skin 
is  more  frequentlj^  than  any  other  surface  in  the  body  the  seat  of  wounds 
— the  most  common  exciting  cause  of  this  disease.  Indeed,  not  only 
must  we  look  upon  eiysipelas  as  a  disease  that  ma}’-  affect  an}^  surface, 
external  or  internal,  but  we  must  consider  the  constitutional  disturbance 
that  takes  place  in  eiysipelas  as  the  essential  morbid  condition.  This, 
it  is  true,  is  usually  complicated  with  diffuse  inflammation  of  the  integu¬ 
ment  and  areolar  tissue,  and  then  constitutes  one  of  the  ordinary  forms 
of  erysipelas.  But  a  constitutional  fever  ma}’-  occur  of  precisely  the  same 
type  as  that  which  we  observe  to  precede  and  to  accompau}^  the  local 
inflammation,  without  any  such  complication.  This  I  had  special  occa¬ 
sion  to  observe  in  a  veiy  fatal  outbreak  of  erysipelas  that  took  place  in 
one  of  my  wards  some  3"ears  ago.  On  that  occasion,  all  the  cases  in 
which  the  cutaneous  form  of  eiysipelas  appeared  were  marked  b}’’  severe 
constitutional  disturbance,  attended  b^^  much  gastro-intestinal  irritation. 
But  precisely  the  same  tjqie  of  general  febrile  S3''mptoms,  and  the  same 
irritation  of  the  stomach  and  bowels,  occurred  in  patients  in  the  same 
ward  in  whom  no  local  or  surface  evolution  of  the  disease  took  place. 
The  true  patholog3"  of  the  diffuse,  low,  or  eiysipelatous  inflammations 
has  3’et  to  be  made  out.  They  are  all  closely  connected  with  one  another, 
and  are  evidently  blood  or  constitutional  diseases,  under  whatever  name 
the3’  go.  The  similarit3^  of  causes,  of  effects,  and  of  constitutional  dis¬ 
turbance,  makes  it  probable  that  they  are  all  essentially  dependent  on 
one  common  condition  of  the  blood ;  and  that  the  particular  local  mani- 


CAUSES  OF  ERYSIPELAS. 


589 


festation  that  occurs,  whether  it  be  erysipelas,  phlebitis,  low  cellulitis, 
or  diffuse  abscess,  is  secondary  to  this,  and  perhaps  in  some  degree 
accidental. 

A  chief  characteristic  of  this  erysipelatous  fever  is  its  incompatibility 
with  the  localization  of  any  inflammation  that  may  exist  at  or  occur 
after  its  invasion ;  and  hence,  when  it  attacks  the  system,  it  causes 
already  existing  inflammations  to  become  diffuse  or  spreading,  and  to 
extend  themselves  over  any  surface  on  which  they  happen  to  be  situated. 
It  is,  in  fact,  the  very  antithesis  of  the  adhesive  inflammation ;  and  not 
only  is  it  so,  but  when  erysipelas  attacks  a  wound  in  which  the  healing 
process  has  made  any  progress,  it  has  a  tendenc}’^  to  disorganize  the 
already  deposited  lymph,  to  open  up  the  wound,  and  to  lead  to  the 
establishment  of  suppurative  action  in  it.  It  is  especially  apt  to  cause 
those  inflammations  to  spread,  which  have  not  already  been  localized  by 
the  deposit  of  adhesive  matter.  Hence,  recent  wounds  are  more  liable 
to  be  affected  by  it  than  old,  and  more  especially  granulating  ones,  in 
wliich  the  inflammation  has  alread}^  taken  on  a  plastic  character,  which 
requires  to  be  overcome  before  the  diffuse  form  can  set  in. 

The  constitutional  fever  in  erysipelas,  although  usually  at  first  sthenic, 
very  speedily  runs  into  an  asthenic  or  irritative  t3q3e,  presenting  in  severe 
cases  the  usual  t3q)hoid  S3’^mptoms — a  quick  feeble  pulse,  brown  tongue, 
pungent  hot  skin,  and  muttering  delirium.  The  disease  is  trul3"  an  affec¬ 
tion  of  debilit3" ;  it  is  in  consequence  of  the  want  of  a  sufficient  degree  of 
power  in  the  part,  or  in  the  system,  for  the  deposit  of  plastic  matter,  and 
the  limitation  of  the  inflammation  1)3’^  this,  that  the  local  affection  spreads 
itself  unchecked  along  the  surface  it  invades.  The  tendency  that  inva¬ 
riably  exists  in  eiysipelas  to  the  occurrence  of  sloughing  and  suppura¬ 
tion  of  the  affected  tissues,  is  a  further  indication  of  the  asthenic  and 
low  character  of  the  disease.  This  view  of  the  nature  of  the  constitu¬ 
tional  disturbance  in  eiysipelas  is  of  great  importance  in  reference  to 
the  treatment  of  the  disease,  as  it  demonstrates  the  necessit3"  of  not 
lowering  the  patient’s  powers  too  much  during  the  early  period  of  the 
affection,  when  it  often  temporarily  assumes  a  trul3^  sthenic  character. 

Er3^sipelas  is  especially  apt  to  become  complicated  with  low  visceral 
inflammation;  the  membranes  of  the  brain,  the  bronchi  and  the  lungs, 
or  the  gastro-intestinal  mucous  surface,  are  commonly  implicated  in  this 
wa3' ;  and  it  is  often  through  these  complications  that  death  results. 

Causes. — Eiysipelas  ma3'  occur  without  any  external  vround,  injury, 
or  lesion  of  an3^  kind,  being  occasioned  by  some  external  agenc3',  such 
as  cold  acting  injuriousl3^  on  a  S3^stem  previousl3'  disposed  to  its  occur¬ 
rence  b3^  habitual  derangement  of  health.  Or  it  may  be  directly  excited 
by  the  infliction  of  a  wound  in  an  individual  who  is  either  strongl3'’ 
predisposed  to  its  occurrence  b3^  previous  constitutional  derangement, 
or  who  is  after  the  receipt  of  this  injuiy  exposed  to  circumstances  that 
favor  the  development  of  the  disease.  Eiysipelas  ma3^  be  predisposed 
to  by  two  distinct  sets  of  causes:  1.  Those  that  are  intrinsic  to  the 
patient — that  are  constitutional,  dependent  upon  the  state  of  his  general 
health ;  and  2.  Those  that  are  extrinsic — those  conditions  of  life  to 
which  he  has  habitually  been  exposed,  or  by  which  he  is  surrounded 
after  the  injuiy  or  operation  to  which  he  has  been  subjected. 

1.  Intrinsic  Causes. — The  great  predisposing  cause  of  erysipelas  is  to 
be  sought  for  and  will  be  found  in  a  want  of  attention  to  hygienic  condi¬ 
tions.  It  is  one  of  the  penalties  inflicted  by  nature  on  those  who  neglect 
those  prime  requisites  of  health — temperance  and  cleanliness,  or  who 
are  incapable  of  obtaining  good  food  and  pure  air.  Were  the  laws  of 


590 


ERYSIPELAS. 


Ii3"giene  attended  to  as  they  should  be,  eiysipelas  and  the  allied  diffuse 
inflammations  would  scarcely  be  met  with  in  surgical  practice.  Some 
persons  appear  to  be  naturally  predisjjosed  to  eiysipelas  to  so  great  a 
degree,  that  the  application  of  cold,  or  slight  stomach-derangement,  or  a 
trivial  superflcial  injuiy,  ma}^  excite  it.  This  predisposition  is  most 
generally  acquired  b}^  habitual  derangement  of  health,  and  is  especially 
induced  b}"  aii}^  of  the  depressing  causes  of  disease,  such  as  over-fatigue, 
anxiety  of  mind,  night-watching,  and  habitual  disregard  of  hygienic 
rules  as  to  diet,  exercise,  air,  etc.  The  habit  of  bod^q  however,  in  which 
eiysipelas  is  most  frequently  met  with  as  a  consequence  of  veiy  trivial 
exciting  causes,  is  that  which  is  induced  b}^  the  habitual  use  of  stimu¬ 
lants  to  excess.  It  is  more  especially  in  that  state  of  the  system 
characterized  by  an  admixture,  as  it  were,  of  irritabilit3’  and  of  debility, 
in  which  inflammation  is  not  followed  by  the  deposition  of  plastic  tymph, 
but  has  a  rapid  tendenc}^  to  the  formation  of  pus  and  slough,  and  to 
extension  of  disease  in  a  diffuse  form,  that  erj’sipelas  is  very  readily 
induced.  This  state  is  met  with  amongst  the  laboring  poor,  as  the 
result  of  the  privation  of  the  necessaries  of  life  conjoined  with  the 
habitual  over-use  of  stimulants  and  exposure  to  the  various  depressing 
conditions  of  bad  food,  impure  air,  etc.  Among  the  wealthier  classes  it 
occurs  as  a  consequence  of  high  living,  want  of  exercise,  and  general 
indulgence  in  luxurious  and  enervating  habits,  leading  to  imperfect 
depuration  of  the  blood,  in  consequence  of  which  that  fluid  is  loaded 
with  effete  materials. 

Some  diseased  states  of  the  blood  appear  to  predispose,  in  the  highest 
degree,  to  the  supervention  of  eiysipelas.  This  is  especially  the  case  in 
diabetes,  and  in  granular  disease  of  the  kidne^^s  attended  b3^  albuminuria. 
As  a  consequence  of  renal  disease,  eiysipelas  will  occur  idiopathicalty, 
or  from  the  most  trivial  causes ;  such  as  a  scratch,  the  sting  of  an  insect, 
or  any  of  the  minor  operations  in  surgery,  more  especialty  about  the 
lower  part  of  the  bod3".  Not  only  is  it  readity  induced  in  this  wa3q  but 
it  will  extend  in  an  uncontrollable  manner  in  these  states  of  the  S3"stem, 
and  will  often  assume  a  gangrenous  form,  there  being  apparentty  an  utter 
want  of  limiting  or  reparative  power  in  any  inflammation,  however  set 
up.  Persons  of  a  gross  and  plethoric  habit,  with  a  tendenc3'  to  gout, 
are  predisposed  to  the  occurrence  of  erysipelas.  The  blood-degeneration 
that  attends  malignant  disease  peculiarty  disposes  to  eiysipelas,  w'hich 
accordingly  more  frequently  takes  place  after  operations  on  persons 
having  such  diseases  than  after  the  removal  of  simple  tumors. 

Persons  whose  nervous  systems  are  habitually  depressed,  the  semi- 
idiotic  and  idiotic  for  instance,  are  very  prone  to  low  diffuse  and  slough¬ 
ing  inflammations  of  an  erysipelatous  form. 

2.  Extrinsic  Causes. — Amongst  the  circumstances  that  surround  the 
patient,  and  that  tend  to  the  production  of  this  disease,  season  of  the 
year  and  atmospheric  changes  exercise  a  marked  influence.  Not  onty  is 
erysipelas  much  more  frequent  in  the  spring  and  autumn  than  at  other 
seasons  of  the  year,  but  we  not  unfrequently  And  it  coming  on  suddenly 
on  the  setting-in  of  cold  easterly  winds,  or  on  the  occurrence  of  sudden 
atmospheric  vicissitudes.  Eiysipelas  often  becomes  epidemic  as  the 
result  of  those  peculiar  but,  at  present,  inexplicable  conditions  of  the 
atmosphere,  in  which  disease  generally  assumes  a  low  type,  and  in  which 
epidemic  catarrhs,  influenza,  phlebitis,  and  other  allied  affections  prevail. 
Epidemic  erysipelas  is  almost  invariably  of  a  low  form,  and  is  very 
commonly  associated  with  some  peculiar  train  of  visceral  complications 
that  distinguishes  the  particular  outbreak  of  the  disease. 


CAUSES  OF  ERYSIPELAS. 


591 


But  not  only  is  er3^sipelas  epidemic ;  it  is  also  contagious.  The  con¬ 
tagion  of  erysipelas,  after  having  been  repeatedly  denied,  can  no  longer 
be  contested.  Travers,  Copland,  Bright,  Nunneley,  and  others,  have 
adduced  cases  in  proof  of  its  contagious  character ;  and  instances  have 
repeatedly  fallen  under  in}’’  own  observation,  in  which  er^’sipelas,  often 
unfortunately  fatal,  has  been  communicated  to  servants,  nurses,  or  rela¬ 
tives  of  patients  affected  by  it.  A  remarkable  jiroof  of  the  contagious 
nature  of  erysipelas  occurred  in  the  winter  of  1851,  in  one  of  my  wards 
at  University  College  Hospital.  The  Hospital  had  been  free  from  any 
cases  of  the  kind  for  a  considerable  time,  when,  on  the  15th  of  January, 
at  about  noon,  a  man  was  admitted  under  m}’’  care  with  gangrenous 
erysipelas  of  the  legs,  and  placed  in  Brundrett  Ward.  On  my  visit  two 
hours  after  his  admission,  I  ordered  him  to  be  removed  to  a  separate 
room,  and  directed  the  chlorides  to  be  freely  used  in  the  ward  from  which 
he  had  been  taken.  Notwithstanding  these  precautions,  however,  two 
days  after  this,  a  patient,  from  whom  a  necrosed  portion  of  ilium  had 
been  removed  a  few  weeks  previously,  and  who  was  Ijdug  in  the  adjoining 
bed  to  that  in  which  the  patient  with  the  erysipelas  had  been  temporarily 
placed,  was  seized  with  eiysipelas,  of  which  he  speedily  died.  The  dis¬ 
ease  then  spread  to  almost  every  case  in  the  ward,  and  proved  fatal 
to  several  patients  who  had  recently  been  operated  upon.  In  some 
instances  patients  were  affected  with  the  constitutional  symptoms  without 
an}"  appearance  of  local  inflammatory  action,  but  characterized  by  the 
same  gastro-intestinal  irritation  that  marked  the  other  cases. 

Erysipelas  may  not  only  spread  in  this  way  from  patient  to  patient,  but 
any  diffuse  inflammation.,  as  phlebitis,  inflammation  of  the  absorbents, 
low  or  puerperal  peritonitis,  and  pyaemia,  may  give  rise  to  external 
erysipelas,  and  in  its  turn  be  occasioned  by  it — a  strong  argument  in 
favor  of  the  allied  nature  of  all  these  affections.  Then,  again,  the 
contact  of  dead  or  putrescent  animal  matters  with  recent  wounds  may 
occasion  it.  In  this  way  the  disease  is  not  unfrequently  originated  in 
hospitals  by  dressers  going  direct  from  the  dead-house,  and  especially 
from  the  examination  of  the  bodies  of  those  who  have  died  of  diffuse 
inflammation,  to  the  bedside  of  patients,  without  taking  sufficient  care 
to  wash  their  hands  or  change  their  clothes.  For  this  reason  also  it  is 
of  great  consequence  that  the  same  instruments  be  not  used  for  practising 
operations  on  the  dead,  and  performing  them  on  the  living  body.  Ovei'- 
croM;6?i7i^  of  hospitals,  and  want  of  proper  ventilation  in  wards  or  rooms, 
are  fertile  sources  of  erysipelas,  and  of  the  allied  low  inflammations ;  in 
fact,  an  outbreak  of  erysipelas  might  at  any  time  be  induced  in  this  way 
amongst  patients  in  all  other  respects  healthy  and  well  cared  for. 

The  principal  Exciting  Cause  of  erysipelas  is  certainly  the  presence 
of  a  wound.  It  is  chiefly  recent  wounds,  however,  that  are  affected ; 
when  once  the  adhesive  or  suppurative  inflammation  is  set  up,  the  wound 
is  not  so  liable  to  take  it  on  unless  it  be  in  bad  constitutions,  the  forma¬ 
tion  of  limiting  fibrine  appearing  to  lessen  the  liability  to  the  occurrence 
of  the  disease.  When  erysipelas  is  epidemic,  it  is  well  for  the  Surgeon 
not  to  perform  any  operation  that  can  conveniently  be  postponed  until 
it  is  less  rife  ;  and  in  no  case  should  a  patient  on  whom  an  operation 
has  recently  been  performed  be  put  in  a  neighboring  bed  to  a  case  of 
erysipelas,  or  even  in  the  same  ward.  The  size  of  the  wound  has  little 
influence  on  the  occurrence  of  erysipelas,  which  takes  place  as  readily 
from  a  small  as  from  a  large  one.  But  although  the  mere  size  of  a 
wound  does  not  influence  the  liability  to  the  occurrence  of  erysipelas  in 
it,  which  will  as  readily  follow  a  puncture  as  an  amputation-wound,  yet 


592 


ERYSIPELAS. 


its  character  does.  Thus,  lacerated  wounds  are  much  more  liable  to  be 
followed  by  eiysipelas  than  clean-cut  incisions.  And  the  depth  of  the 
wound  influences  in  an  important  manner  the  severity  of  the  erysipelas, 
which  is  more  intense  in  those  injuries  that  penetrate  the  fascia,  even 
though  this  be  cut  to  a  very  limited  extent,  when  the  disease  may  spread 
widely  and  fatally  through  the  deeper  subaponeurotic  and  intermuscular 
planes  of  areolar  tissue.  Injuries  about  the  head  and  hands  are  those 
that  are  most  liable  to  be  followed  b}^  this  disease. 

But,  though  we  must  constantly  bear  in  mind  the  constitutional  nature 
of  erysipelas,  it  will  be  more  convenient  and  practical  to  describe  it  as 
it  affects  different  tissues  and  organs.  With  this  view,  we  may  divide 
it  primarily"  into  External  and  Internal  Erysipelas. 

EXTERNAL  ERYSIPELAS. 

External  Erysipelas  is  that  variety  of  the  disease  which  affects  the 
skin  and  subcutaneous  areolar  tissue.  This  form  has  been  described 
with  an  absurd  degree  of  minuteness,  so  far  as  the  transitory  and  acci¬ 
dental  characters  of  its  duration,  shape,  and  appearance  are  concerned, 
by  many  of  the  writers  on  Diseases  of  the  Skin ;  who,  in  their  anxiety 
to  record  minute  and  often  accidental  shades  of  difference  in  appearance, 
have  entirely  lost  sight  of  the  true  nature  of  the  disease.  The  division 
adopted  by  Lawrence  into  the  Simple^  the  (Edematous^  and  the  Phleg¬ 
monous  forms,  is  a  practical  arrangement  that  is  commonly  adopted  by 
Surgeons.  I  prefer,  however,  and  shall  adopt,  the  division  made  by 
Nunneley  in  his  very  excellent  work  on  Erysipelas,  as  founded  on  the 
true  pathology  of  the  affection.  He  arranges  external  erysipelas  under 
three  varieties :  I.  Cutaneous;  2.  Cellulo-cutaneous ;  and  3.  Cellular. 

1.  Cutaneous  Erysipelas  is  the  slightest  form  of  the  disease,  im¬ 
plicating  merely  the  skin  ;  it  comprises  man}^  of  the  species  of  erythema 
of  different  writers,  and  corresponds  to  the  simple  erysipelas  of  Lawrence. 

Local  Signs. — A  patient  is  seized  with  rigors,  alternate  chills  and 
flushes,  followed  by  headache,  nausea,  a  quick  pulse,  a  coated  tongue,  and 
hot  skin ;  in  from  twenty- four  to  forty-eight  hours  the  rash  appears, 
though  sometimes  it  comes  out  simultaneousl}’-  with  the  constitutional 
disturbance.  If  there  be  a  wound,  the  secretions  of  this  dry  up,  and 
the  margins  become  slightly  swollen,  and  affected  by  the  red  blush.  If 
the  disease  occur  idiopathically  without  a  wound,  it  most  commonly 
appears  upon  the  face,  next  upon  the  legs,  and  lastly  upon  the  trunk. 
The  rash  is  of  a  uniform  but  vivid  rosy  red  hue,  sometimes  becoming 
dusky,  and  always  disappearing  on  pressure;  it  usually  fuses  away  into 
the  color  of  the  healthy  skin,  but  sometimes  has  a  distinct  margin.  It 
is  accompanied  by  some  slight  oedematous  swelling,  which  is  often  con¬ 
siderable  where  the  areolar  tissue  is  loose,  as  in  the  eyelids  and  scrotum, 
and  there  is  usually  a  stiff  burning  sensation  in  the  part.  Vesicles  or 
blebs  often  form,  containing  a  clear  but  hot  serum,  which  speedily  be¬ 
comes  turbid,  and  dries  into  brawny  desquamation.  The  redness  may 
spread  rapidly  along  the  limb  or  trunk,  or,  if  the  face  be  affected,  may 
travel  quickl}^  from  one  side  to  the  other,  causing  such  swelling  of  the 
eyelids  as  to  close  them,  and  giving  rise  to  much  tensive  pain  in  the 
ears.  Sometimes  the  disease  appears  in  one  part  of  the  bodjq  reappear¬ 
ing  in  another.  This,  which  is  the  erratic  erysipelas,  is  often  a  danger¬ 
ous  form  of  the  affection,  occurring  in  advanced  stages  of  pyaemia,  and 
indicating  the  approach  of  death.  In  these  varieties  of  idiopathic  ery¬ 
sipelas,  Arnott  states  that  the  fauces  are  always  involved.  This  affec- 


CELLULO-CUTANEOUS  ERYSIPELAS. 


593 


tion  usually  disappears  without  inducing  any  serious  mischief  in  the 
part,  but  in  some  cases  abscesses  form,  more  especiall}^  in  the  loose 
areolar  tissue  of  the  neck  and  of  the  e^'elids.  In  other  cases,  oedema  of 
the  part  continues,  with  some  irritability  and  redness  of  the  skin  and 
peeling  of  the  cuticle ;  and  in  some  rare  cases  the  simple  erysipelas 
seems  to  take  on  a  gangrenous  or  sloughing  character,  especially  about 
the  umbilicus  and  genitals  of  young  children. 

The  Constitutional  Symptoms  of  the  cutaneous  or  simple  erysipelas 
present  every  variety  between  the  sthenic  and  asthenic  forms  of  inflam¬ 
matory  fever.  When  the  disease  occurs  in  London,  it  certainly  most 
frequently  assumes  a  low  type.  There  is  also  in  most  cases  a  good  deal 
of  derangement  of  the  digestive  organs;  the  tongue  being  much  coated, 
with  tenderness  about  the  epigastrium,  dark  offensive  evacuations,  and 
not  unfrequently  diarrhoea.  When  the  scalp  is  aflfected,  severe  headache, 
with  symptoms  of  cerebral  inflammation,  are  commonly  met  with.  Most 
frequently  recovery  takes  place  by  the  gradual  subsidence  of  the  symp¬ 
toms;  this  form  of  the  disease  seldom  proving  fatal  unless  the  scalp  be 
affected,  and  the  brain  consequently  implicated. 

2.  Cellulo-eutaneous  or  Phlegmonous  Erysipelas  differs  from 
the  last  variety  in  the  degree  of  inflammation,  and  in  the  depth  to  which 
the  tissues  are  affected.  The  intensity  of  this  form  of  inflammation  is 
so  great  that  it  invariably  terminates,  if  left  to  itself,  in  difi’used  sup¬ 
puration  and  sloughing.  In  depth  it  alwa3^s  extends  to  the  subcuta¬ 
neous  areolar  tissue,  and,  though  generally  bounded  by  the  fasciae  lying 
beneath  this,  not  unfrequently  implicates  them  if  they  have  been  opened 
up,  extending  to  the  intermuscular  areolar  planes,  the  sheaths  of  the 
tendons,  and  other  deep  structures. 

Local  Signs. — The  cellulo-cutaneous  or  phlegmonous  erysipelas  is 
ushered  in  by  the  ordinary  symptoms  of  inflammatory  fever,  accompanied 
or  followed  by  the  signs  of  severe  inflammation  in  the  part  affected. 
The  redness  is  uniform,  of  a  deep  scarlet  hue,  and  pretty  distinctly 
bounded  ;  the  pain  is  from  the  first  pungent  and  burning,  though  it  may 
soon  assume  a  throbbing  character ;  the  swelling,  at  first  soft,  diffused, 
and  admitting  of  distinct  pitting,  soon  increases,  and  becomes  tense  and 
brawny,  the  skin  being  evidently  stretched  to  its  full  extent,  and  the 
limb  appearing  perhaps  to  be  of  double  its  natural  size.  Large  vesica- 
tions  or  blebs  containing  sero-purulent  fluid,  sometimes  of  a  sanious 
tinge,  appear  in  many  cases.  This  condition  usually  continues  up  to  the 
sixth  or  eighth  day  after  the  invasion  of  the  disease,  during  the  whole 
of  which  time  the  constitutional  symptoms  have  presented  the  ordinary 
type  of  sthenic  inflammatory  fever ;  about  this  time,  however,  a  change 
commonly  takes  place,  either  for  better  or  worse.  If,  under  the  influ¬ 
ence  of  proper  treatment,  and  in  a  tolerably  healthy  constitution,  the 
inflammation  subside,  resolution  takes  place,  with  a  gradual  abatement 
of  all  the  symptoms.  If,  however,  as  usually  happens,  the  disease  run 
on  to  more  or  less  sloughing  or  suppuration  of  the  part,  no  increase  of 
the  swelling,  pain,  or  redness  takes  place,  but,  on  the  contrary,  some 
diminution  of  these  signs  may  occur,  giving  rise  to  a  deceptive 
appearance  of  amendment.  The  skin  becomes  darkly  congested,  and 
the  part,  instead  of  being  tense  and  brawny,  has  a  somewhat  loose,  soft, 
and  boggy  feel,  communicating  a  semi-fluctuating,  doughy  sensation  to 
the  fingers.  This  change  from  a  tense  brawny  state  to  a  semi-pulpy 
condition  indicates  the  formation  of  pus  and  slough  beneath  the  integu¬ 
ment,  and  occurs  without  any  material  alteration  in  the  size,  the  color, 
01  the  general  appearance  of  the  part,  but  can  only  be  detected  by  careful 
VOL.  I. — 38 


594 


ERYSIPELAS. 


palpation  ;  bence  the  Surgeon  must  daily  examine  with  his  own  fingers 
the  state  of  the  part,  and  neither  trust  to  the  reports  of  others,  nor  to 
the  general  appearance  of  the  diseased  structures,  for  a  knowledge  of 
the  probable  condition  of -the  subjacent  tissues.  If  an  incision  be  now 
made  into  the  aflected  part,  the  areolar  membrane  will  be  found  loaded 
wdth  an  opalescent  fluid  distending  its  cells,  but  not  flowing  from  the 
wound  ;  the  retention  of  this  fluid  gives  a  gelatinous  appearance  to  the 
sides  of  the  incision,  which  rapidly  degenerates  into  slough  and  pus.  If 
the  alteration  in  the  structure  have  advanced  to  a  stage  beyond  this,  the 
areolar  tissue  will  be  found  to  have  been  converted  into  dense  masses  of 
slough,  lying  in  the  midst  of  thin  and  unhealthy  ichorous  pus  ;  these 
have  not  inaptly  been  compared  in  appearance  to  masses  of  decomposed 
tow,  of  w’et  chamois  leather,  or  to  the  membranes  of  a  fcetus  a  few 
months  old.  Whilst  these  changes  are  going  on  below  the  surface,  the 
skin,  at  first  congested,  becomes  somewhat  paler,  and  assumes  a  white 
or  marbled  appearance,  rapidly  running  into  black  sloughs,  and  being 
undermined  to  an  immense  extent  by  large  quantities  of  broken-up 
areolar  tissue  and  of  ill  conditioned  pus,  without  any  appearance  of 
pointing,  however  extensive  the  subcutaneous  mischief  may  be.  These 
destructive  changes  expose  muscles,  fasciie,  and  bloodvessels,  and  may 
induce  necrosis  of  the  bones  or  destroy  the  joints.  They  occur  most 
readily  in  those  parts  of  the  body  that  possess  the  lowest  degree  of 
vitality,  and  hence  are  more  common  in  erysipelas  of  the  legs  than  in 
the  same  affection  of  the  scalp.  If  the  patient  recover,  there  will  be 
tedious  cicatrization  of  the  deep  cavities  that  are  left,  or  considerable 
oedema,  often  of  a  solid  character,  a  kind  of  false  hypertroplu'^  of  the 
part,  which  may  continue  for  some  considerable  time.  In  other  cases, 
there  may  be  such  extensive  local  destruction  or  gangrene  of  the  soft 
tissues,  with  exposure  and  death  of  the  bones  or  suppuration  of  the 
joints,  that  amputation  of  the  limb  may  be  required  to  save  the  patient’s 
life.  No  operation  of  this  kind,  however,  should  ever  be  practised  for 
the  consequences  of  erysipelas,  unless  these  be  strictly  localized,  with 
no  tendency  to  spread,  nor  until  specific  constitutional  fever  has  been 
completely  removed,  except  such  as  is  of  a  hectic  character,  and  depen¬ 
dent  on  the  exhausting  influences  of  the  suppuration  and  disorganization 
of  tissues. 

During  the  progress  of  these  local  changes,  the  Constitutional  Symp¬ 
toms  have  assumed  corresponding  modifications.  At  first  of  an  active 
inflammator}^  character,  the  fever,  when  suppuration  and  sloughing  have 
set  in,  often  suddenly  becomes  asthenic  ;  although  in  some  cases  there 
is  no  diminution  in  the  severity  of  the  symptoms,  until,  after  an  attempt 
for  a  few  days  to  bear  up  against  the  exhausting  influence  of  the  disease, 
the  constitution  gradually  gives  way  and  death  speedily  supervenes.  If 
the  patient  survive  the  stage  of  sloughing,  and  if  the  discharge  continue 
abundant,  hectic,  with  diarrhoea,  gastro-intestinal  irritation,  metastatic 
abscesses,  or  py£emia,  may  carry  him  off.  If  recovery  eventually  take 
place,  it  may  be  at  the  expense  of  a  constitution  impaired  and  shattered 
for  years.  This  disease  is  most  dangerous  in  the  old  and  infirm,  or  in 
young  children.  The  immediate  danger  is  always  greatest  when  the 
head  is  affected,  from  the  extension  of  the  disease  to  the  membranes  of 
the  brain,  and  the  supervention  of  erysipelatous  arachnitis.  The  remote 
danger  from  the  effects  of  suppuration,  necrosis,  and  inflammation  of  the 
joints,  is  greatest  when  the  lower  extremities  are  the  seat  of  erysipelas. 

A  variety  of  the  cellulo-cutaneous  erysipelas  has  been  described  as 
(Edematous  Erysipelas.  By  this  is  meant  not  merely  the  effusion  into 


CELLULAR  ERYSIPELAS. 


595 


the  areolar  tissue  which  occurs  in  all  the  varieties  of  the  disease,  but  a 
peculiar  form,  specially  marked  by  oedema  of  the  areolar  tissue,  with  less 
inflammation  of  the  skin  than  usual.  There  is  much  swelling,  which  pits 
deeply,  with  but  little  pain  or  tension,  and  but  moderate  redness  of  the 
skin;  the  constitutional  S3’mptoms  are  less  marked  than  in  the  other 
varieties  of  the  disease;  it  is  principally^  met  wdth  in  old  people,  or  in 
persons  of  a  dropsical  tendency^,  in  whom  it  occurs  especially  about  the 
legs,  scrotum,  or  labia,  sometimes  giving  rise,  by  the  effusion  of  a  sero- 
plastic  fluid,  to  permanent  and  solid  enlargement. 

3.  Cellular  Erysipelas,  or,  as  it  is  often  termed.  Diffuse  Inflamma¬ 
tion  of  the  Cellular  Tissue^  or  Cellulitis^  has  been  particularly  described 
by’  Duncan,  Arnott,  Lawrence,  and  Xunneley.  It  alway’S  arises  from  a 
wound  or  injury,  often  of  an  apparently  trivial  character,  and  most  com¬ 
monly  affects  the  subcutaneous  areolar  membrane,  though  occasionally^ 
it  extends  to  the  subaponeurotic  tissue,  and  then  is  a  more  severe  and 
dangerous  affection.  Though  commonly^'  arising  as  a  consequence  of 
ordinaiy  injuries,  it  is  especially^-  apt  to  follow  those  in  which  there  has 
been  any^  inoculation  of  animal  poisons,  as  dissection  wounds,  the  stings 
of  insects,  and  the  bites  of  venomous  reptiles.  In  whatever  way  arising, 
it  is  characterized  by  the  rapidity’  and  extent  of  the  sloughing  of  the 
affected  tissue,  and  by  great  depression  of  the  powers  of  the  constitu¬ 
tion.  That  the  diffuse  inflammation  of  the  areolar  tissue,  whether  it  be 
limited  to  a  finger,  or  implicate  the  areolar  membrane  of  half  the  bodyq 
is  a  variety  of  eiysipelas  affecting  this  membrane  primarily’,  and  the  skin 
secondarily,  there  can  be  no  doubt.  The  points  of  resemblance  between 
cellulitis  and  erysipelas  have  been  well  shown  by  Xunneley^  Not  only’- 
are  the  local  effects  precisely  the  same  in  the  two  diseases — the  same 
swelling,  tension,  infiltration  of  pus,  and  formation  of  gangrenous  shreds 
and  sloughs;  but  the  constitutional  sy’mptoms, though  differing  perhaps 
in  degree,  present  no  variety’-  as  to  character.  The  results  also  are  iden¬ 
tical,  there  being  the  same  local  impairment  of  structure,  the  same  ten- 
dency^  to  involve  parts  at  a  distance,  and  to  the  formation  of  secondary’ 
abscesses.  These  two  forms  of  disease  occur  in  the  same  constitutions, 
in  the  same  states  of  the  atmosphere,  and  in  the  same  situation ;  one  may 
produce  the  other;  and  lastly,  the  same  treatment  is  required  for  both. 

Local  Signs. — There  are  great  swelling,  tension,  and  pain  in  the  limb, 
which  feels  brawny  in  some  parts,  oedematous  in  others.  The  skin  is 
slightly^  reddened  in  patches,  has  a  mottled  appearance,  and  speedily^ 
runs  into  blackish  sloughs.  The  extent  to  which  the  disease  may  spread 
varies  greatly;  when  once  it  has  set  in,  it  commonly^  runs  rapidly  up 
the  whole  of  a  limb,  extending  also  to  the  sides  of  the  trunk ;  in  other 
cases,  its  violence  appears  to  be  principally^  expended  at  a  distance  from 
the  seat  of  injury’;  thus,  in  a  case  of  a  punctured  wound  of  the  finger, 
the  diffuse  inflammation  may^  principally  take  place  in  the  extended 
planes  of  areolar  tissue  about  the  axilla  and  sides  of  the  chest.  It  is 
important  to  bear  in  mind  that  this  form  of  ery’sipelas  sometimes  affects 
the  internal  planes  of  areolar  tissue.  This  may  happen,  for  instance,  in 
the  fasciae  of  the  pelvis  after  lithotomy’,  or  in  the  anterior  mediastinum 
after  operations  at  the  root  of  the  neck.  The  sloughing  often  occurs 
with  remarkable  rapidity’  in  the  course  of  thirty’-six  or  forty’-eight  hours, 
the  areolar  membrane  being  broken  down  into  ill-conditioned  pus  and 
shreddy’  sloughs,  more  especially  when  the  disease  has  resulted  ft*om  the 
inoculation  of  an  animal  poison.  Death  may  in  such  cases  occur  in  two 
or  tliree  day’s;  in  other  instances,  several  weeks  elapse  before  a  fatal 
result  declares  itself. 


596 


ERYSIPELAS. 


The  Constitutional  Symptoms  are  those  of  asthenic  fever  in  the  most 
marked  degree ;  a  quick  and  feeble  pulse,  brown  tongue  and  muttering 
delirium,  being  early  concomitants  of  this  affection. 

Diagnosis. — The  diagnosis  of  the  various  forms  of  erysipelas  is  gene¬ 
rally  easily  made.  From  the  exanthemata^  it  is  distinguished  by  the 
character  of  the  eruption,  its  limited  extent,  and  usual  complication  with 
injury.  From  inflammation  of  the  veins  or  of  the  absorbents^  the  diag¬ 
nosis  is  not  always  easy,  more  especially  as  the  two  conditions  frequently 
coexist.  If  it  be  a  vein  that  is  inflamed,  the  general  absence  of  cuta¬ 
neous  redness,  the  existence  of  a  hard  round  cord,  and  the  tenderness 
along  the  course  of  the  vessel,  are  sufficient  to  establish  the  diagnosis. 
In  inflammation  of  the  absorbents,  the  redness  is  not  uniform,  but  con¬ 
sists  of  a  number  of  small  and  separate  red  streaks,  running  in  the  direc¬ 
tion  of  the  lymphatics,  and  affecting  the  glands  towards  wdiich  they  course. 
These  two  affections,  however — erysipelas  of  the  skin  and  inflammation 
of  the  absorbents— are  almost  invariably  conjoined ;  hence  a  definite 
diagnosis  is  not  of  much  importance. 

Prognosis. — The  prognosis  in  any  case  of  erysipelas  depends  on  a 
variety  of  circumstances.  The  form  of  the  disease  influences  greatly 
the  result;  the  cutaneous  variety  being  attended  with  least  danger,  the 
cellular  with  the  most.  The  traumatic  is  more  dangerous  than  the  idio¬ 
pathic  form.  Much  also  depends  on  the  seat  of  the  affection  ;  that  at¬ 
tacking  the  head  and  lower  limbs  being  the  most  dangerous;  encepha¬ 
litis  being  apt  to  ensue,  wdien  the  head  is  affected.  When  the  legs  are 
extensivel}’  implicated,  sloughing  of  the  skin  and  areolar  tissue,  with 
denudation  of  the  bones  and  destruction  of  the  joints,  may  occur.  The 
disease,  in  all  its  forms,  is  most  dangerous  at  either  of  the  extremes  of 
life.  If  the  constitution  be  sound,  very  extensive  mischief  may  be 
recovered  from  ;  if,  on  the  other  hand,  it  be  depressed  or  broken  by  want 
of  the  necessaries  of  life,  by  fatigue,  over-exertion,  or  indulgence  in 
stimulants,  a  very  slight  amount  of  disease  may  prove  fatal.  The  most 
dangerous  complication  of  erysipelas,  and  one  which  when  it  exists 
almost  precludes  the  hope  of  recovery,  is  chronic  disease  of  the  kidneys., 
either  in  a  form  of  the  granular  contracted,  or  of  the  large  white  kidney, 
with  albuminuria.  I  have  never  seen  any  patient  laboring  under  these 
diseases,  and  attacked  with  traumatic  er3^sipelas,  escape  with  life ;  the 
sloughing  and  suppuration  running  on  unchecked  b^^  any  treatment  that 
could  be  adopted.  The  particular  type  which  the  erysipelas  may  assume, 
and  the  occurrence  of  gastro-intestinal  or  pulmonary  complications,  will 
also  seriously  affect  the  result. 

Treatment. — Preventive  Measures. — The  occurrence  of  er^’sipelas 
is  best  guarded  against  b}^  attention  to  hygienic  measures,  more  particu- 
larl}’'  proper  ventilation  with  pure  air,  and  the  avoidance  of  overcrowding 
of  patients.  In  hospitals,  erysipelas  might  be  produced  at  any  time  by 
want  of  attention  in  these  respects,  and  the  frequency  of  its  occurrence 
may  most  materiall}^  be  lessened  by  careful  regulation  of  the  hygienic 
conditions  that  surround  the  patient.  With  every  care,  however,  ery¬ 
sipelas  can  never  be  completel}^  eradicated  from  surgical  wards,  as  the 
conditions  that  lead  to  its  development  have  influenced  the  patients  so 
deeply  before  their  admission  into  hospital,  that  no  subsequent  attention 
can  prevent  its  occurrence  afterwards.  It  often  happens  that  erysipelas 
is  unusuall}"  frequent  in  certain  wards  and  even  in  certain  beds.  Its 
persistence  in  these  respects  will  be  found  to  be  owing  to  some  local 
cause,  such  as  the  emanations  from  a  drain,  on  the  removal  of  which  the 
disease  wdll  cease.  Scrupulous  attention  to  cleanliness  also  on  the  part 


TREATMENT  OF  CUTANEOUS  ERYSIPELAS. 


597 


of  nurses  and  dressers  should  be  enforced,  and  the  latter  should  not  be 
allowed  to  go  straight  from  the  dead-house  to  the  ward  without  previ¬ 
ously  washing  their  hands  in  some  chlorinated  solution.  When  ery¬ 
sipelas  has  already  occurred,  its  further  spread  may  be  prevented  by 
isolating  the  patients  affected,  and  at  once  taking  active  measures  to 
purify  the  ward  from  which  they  have  been  removed. 

The  Guratwe  Treatment  of  erysipelas  must  always  be  conducted  with 
reference  to  the  low  character  of  the  local  inflammation,  its  tendjency  to 
run  into  suppuration  and  gangrene,  the  asthenic  type  that  the  constitu¬ 
tional  fever  readily  assumes,  and  the  frequent  complication  of  the  visce¬ 
ral  inflammations  of  a  congestive  form.  The  apparent  intensitj''  .of  the 
local  inflammation  must  not  lead  the  Surgeon  into  the  fatal  error  of 
employing  an  over-active  anti-inflammatory  treatment,  more  particularly 
if  the  disease  be  epidemic,  when  it  always  assumes  a  low  type.  It  is 
especially  important  to  look  to  the  future,  and  to  remember  that,  if  active 
depletoiy  measures  be  employed  early  with  a  view  of  lessening  the 
present  disease,  it  will  be  at  the  risk  of  inducing  more  extensive  slough¬ 
ing,  and  perhaps  of  lowering  the  patient’s  powers  to  such  a  degree  as  to 
prevent  his  bearing  up  under  the  depressing  influence  of  the  conse¬ 
quences  of  the  disease. 

In  the  Treatment  of  Cutaneous  or  Simple  Erysipelas^  we  must  first 
clear  out  the  stomach  and  bow'els  b3"an  ipecacuanha  emetic,  followed  b^" 
a  calomel  and  coloc^mth  pill  and  some  saline  aperient.  If  the  patient 
be  3mung  and  robust,  and  the  disease  be  somewhat  sthenic,  he  should  be 
kept  on  a  mild  diet,  and  take  diaphoretic  salines  every  fourth  or  sixth 
hour.  If  the  patient  be  advanced  in  3’ears,  and  the  disease  assume  a 
lower  form,  the  acetate  of  ammonia  in  camphor  mixture  ma3^  be  admin¬ 
istered.  If  the  disease  from  the  first  be  of  a  low'  t3'pe,  or  if  it  subside 
into  this,  the  carbonate  of  ammonia  in  ten-grain  doses  should  be  added 
to  the  preceding  mixture,  in  which  the  decoction  of  bark  ma3'  then  be 
substituted  for  the  camphor  julep.  In  maiy*  of  the  low  forms  of  ery¬ 
sipelas,  medicines  are  not  well  borne,  the  stomach  rejecting  them  ;  and 
then  I  have  seen  the  best  possible  results  follow  the  free  administration 
of  the  brand3'-aud-egg  mixture,  to  which  I  am  in  the  habit  of  trusting  in 
the  majorit3'  of  these  cases.  During  the  progress  of  the  disease,  simple 
purgatives  must  be  given  from  time  to  time.  In  anaemic  and  cachectic 
individuals  no  remed3’’  exercises  so  beneficial  an  influence  as  the  tincture 
of  sesquichloride  of  iron,  administered  in  doses  of  twenty  minims  eveiy 
third  or  fourth  hour. 

The  Local  Treatment  of  this,  as  of  eveiy  variet3^  of  erysipelas,  is  of 
equal  importance  with  the  constitutional  management.  Warm  applica¬ 
tions  assiduously  continued,  especiall3'  popp3’  and  chamomile  fomenta¬ 
tions  applied  b3'  means  of  flannels  or  spongio-piline,  afford  the  greatest 
possible  relief.  Cold  lotions  should  never  under  an3’’  circumstances  be 
emplo3'ed  ;  the3'  not  01113'  lessen  the  vitalit3'  of  the  part,  and  thus  favor 
local  sloughing,  but  they  may  chance  to  cause  a  retrocession  of  the  dis¬ 
ease,  and  the  constant  affection  of  some  internal  organ.  The  local 
abstraction  of  blood  and  of  serum  from  the  inflamed  part,  ly  the  plan 
introduced  by  Sir  R.  Dobson,  of  rapidl3’  making  with  the  point  of  a  lancet 
a  large  number  of  small  punctures,  from  a  quarter  to  half  an  inch  deep, 
is  of  much  value,  by  lessening  the  tension  and  sw’elling,  and  consequently 
diminishing  the  inflammatoiy  action  ;  a  warm  fomentation  cloth  or  poul¬ 
tice  should  be  laid  over  the  punctures  so  as  to  encourage  bleeding,  and 
the  escape  of  serum.  Astringent  applications  to  the  inflamed  surface, 
such  as  a  strong  solution  of  the  nitrate  of  silver,  are  recommended  b3' 


598 


ERYSIPELAS. 


some  Surgeons.  I  have  seen  them  rather  extensively  employed  by  A.T. 
Thomson,  but  not  with  aii}^  very  marked  success.  A  boundaiy  line  of 
nitrate  of  silver  is  occasionally  drawn  around  the  inflamed  part,  with  a 
view  of  checking  the  extension  of  the  disease.  I  have  often  done  this, 
and  seen  it  done  by  others,  but  never  apparently  with  any  benefit ;  and 
have  now  discontinued  the  practice  as  a  useless  source  of  irritation. 
The  application  of  a  bandage  is  occasionally  necessaiy  after  the  disap¬ 
pearance  of  the  erysipelas,  in  order  to  remove  the  oedema  that  remains. 

In  the  Treatment  of  Gellulo-cutaneous  Ei'ijmpelas,,  more  energetic 
constitutional  and  local  means  are  required.  In  the  early  stage,  our 
object  is  to  prevent  the  inflammation  from  running  into  gangrene  of  the 
affected  tissue.  The  fever  being  at  this  period  commonl}"  sthenic,  the 
more  active  administration  of  purgatives,  antimonials,  or  effervescent 
salines  is  required.  I  have  never  seen  a  case  in  which  blood-letting  was 
required;  and  depressing  remedies,  such  as  salines,  should  be  given 
with  great  caution.  The  best  plan  is,  perhaps,  to  give  an  emetic  and 
purge,  to  clear  out  the  stomach  and  bowels,  and  then  to  give  effervescing 
salines,  with  carbonate  of  ammonia,  in  full  doses  of  gr.  x.  to  gr.  xv.  As 
the  disease  advances,  and  sj^mptoms  of  more  or  less  depression  come  on, 
it  may  be  necessary  to  effect  that  gradual  change  to  a  more  stimulating 
plan  of  treatment,  which  has  already  been  described  in  speaking  of 
the  management  of  inflammatory  fever.  In  doing  this,  the  pulse  and  the 
tongue  must  be  our  guides ;  as  the  one  becomes  feebler  and  the  other 
browner,  so  must  ammonia,  bark,  and  especiall3^  port  wine,  and  the 
brandy-and-egg  mixture,  be  administered.  In  the  more  advanced  stages 
of  the  disease,  when  sloughing  and  suppuration  are  fully  established, 
our  sole  object  must  be  by  nourishing  diet,  and  the  use  of  stimulants 
and  tonics,  more  particularly  the  tincture  of  sesquichloride  of  iron,  to 
bear  the  patient  through  the  depression  and  subsequent  hectic. 

The  Local  Treatment  cellulo-cutaneous  or  phlegmonous  erysipelas 
must  be  conducted  on  essentially  the  same  plan  as  that  of  the  cutaneous 
variety,  though  with  more  active  means.  The  part  affected  must  be 
kept  at  rest,  must  be  elevated  if  it  be  a  limb,  and  have  hot  chamomile 
and  poppy  fomentations  assiduously^  applied,  cold  being  more  prejudicial 
here  even  than  in  the  last  form  of  the  disease;  in  this  way,  the  swelling 
and  tension  may  perhaps  be  removed,  and  the  sloughing  of  the  areolar 
tissue  prevented.  In  the  majority  of  cases,  however,  other  means  will  be 
required  to  effect  this,  and  with  this  view  none  are  more  efficacious  than 
incisions  made  into  the  part ;  by  these  an  outlet  is  afforded  for  the  blood 
and  effused  serum,  which,  by  distending  the  vessels  and  cells  of  the 
part,  produce  strangulation  of  the  tissues  and  consequent  sloughing. 
This  mode  of  practice,  originally  introduced  by  Hutchinson,  is  generally 
allowed  to  be  the  most  effectual  means  we  possess  for  the  prevention  of 
sloughing;  hence  the  incisions  should  be  made  early,  before  there  has 
been  time  for  the  tissues  to  lose  their  vitality.  So  soon,  indeed,  as  they 
have  become  brawny,  indurated,  and  tense,  incisions  properly  made  and 
placed  will  afford  the  greatest  possible  relief  to  the  part  and  the  patient, 
taking  down  the  tension  by  the  gaping,  and  the  swelling  by  the  exit 
they  afford  to  blood  and  serum.  Much  difference  of  opinion  has  existed 
among  Surgeons,  as  to  the  extent  to  which  incisions  should  be  practised 
in  these  cases ;  some  recommending  that  one  long  cut  should  be  made 
through  the  inflamed  structures;  others  contending,  on  the  contrary, 
that  a  number  of  small  incisions  better  answer  the  proposed  end.  The 
objections  to  the  long  incision  are,  that  so  considerable  a  wound  not 
only  inflicts  a  serious  shock  to  the  system,  but  that  the  loss  of  blood 


SPECIAL  FOKilS  OF  EXTERNAL  ERYSIPELAS. 


599 


from  it  ma}^  be  so  great  as  to  be  fatal — cases  having  occurred  in  which 
life  has  been  lost  from  this  cause,  or  the  hemorrhaofe  has  been  arrested 
only  b}^  the  ligature  of  the  main  arter}^  of  the  limb ;  and  also  that  a 
sincrle  Ions:  incision  does  not  relieve  tension  so  effeetuallv  as  a  number 
of  smaller  ones.  The  incisions  consequent!}"  should  be  of  limited  extent, 
from  two  to  three  inches  in  length :  at  most  they  should  not  extend 
deeper  than  into  the  gelatinous-looking  subcutaneous  areolar  tissue, 
unless  it  happen  that  the  disease  have  extended  beneath  the  fascia,  when 
they  may  also  be  carried  through  it.  South  recommends  that  the  inci¬ 
sions  should  be  so  arranged  in  fours,  as  to  inclose  a  diamond-  | 
shaped  wedge,  and  states  that  in  this  way  the  greatest  relief  is  |  | 

given  to  the  tension  of  the  part.  After  the  incisions  have  been  | 
made,  the  part  should  be  well  poulticed  and  fomented,  so  as  to  facilitate 
the  escape  of  serum.  As  it  is  not  the  object  of  the  Surgeon  to  draw 
blood  in  these  cases,  any  undue  amount  of  hemorrhage  should  be 
arrested  b}^  plugging  the  wound.  After  suppuration  and  sloughing 
have  taken  place,  as  indicated  b}"  a  bogg}^  feel  of  the  parts,  free  incision 
should  be  made  in  order  to  let  out  pus  and  sloughs.  After  this,  the  skin 
will  often  be  found  to  be  greatly  undermined,  blue  and  thin,  with  matter 
bagging  in  the  more  dependent  parts  ;  if  so,  egress  must  be  made  for  it 
b}’’  free  counter-openings.  During  the  after-treatment,  frequent  dressing 
•  is  necessary  to  prevent  an  accumulation  of  pus,  and  the  sloughs  must 
be  removed  as  they  form.  Care  should  be  taken  not  to  destro}"  any  of 
the  vascular  connections  of  the  skin  with  subjacent  parts;  but,  in  order 
to  get  proper  cicatrization,  it  will  often  be  found  necessaiy  to  lay  open 
sinuses,  or  to  divide  bridges  of  unhealth}"  and  blue  integument  stretch¬ 
ing  across  chasms  left  by  the  removal  of  the  gangrenous  areolar  tissue. 
If  the  loss  of  substance  be  great,  the  cicatrix  that  forms  may  be  weak, 
imperfect,  or  so  contracted  as  to  occasion  great  deformity  of  the  limb. 
In  other  cases,  again,  the  diseased  state  of  the  bones  and  joints  may  be 
such  as  to  call  for  ultimate  amputation,  either  in  consequence  of  the 
local  deformity  and  annoyance,  or  in  order  to  free  the  constitution  from 
a  source  of  hectic  and  of  irritation.  In  all  circumstances  the  patient’s 
health  will  usually  continue  in  a  feeble  and  shattered  state  for  a  con¬ 
siderable  time  after  recovery  from  this  form  of  erysipelas,  requiring 
change  of  air  and  great  attention  to  habits  of  life,  a  nourishing  diet,  etc. 

In  the  Treatment  of  Cellular  Erysipelas  it  is  usually  necessary  to 
administer  stimulants  early;  ammonia,  wine,  or  brandy  may  be  required 
from  the  very  first.  The  Surgeon  must  judge  of  this  by  the  constitu¬ 
tional  condition  of  the  patient,  and  more  particularly  by  the  state  of  his 
pulse  and  tongue.  The  Local  Treatment  is  precisely  of  the  same  kind 
as  that  adopted  in  phlegmonous  erysipelas,  except  that  the  incisions 
require  to  be  made  earlier  and  perhaps  more  freely;  in  all  other  respects, 
there  is  no  difference  between  the  g-eneral  management  of  the  two  forms 
of  the  disease. 

Special  Forms  of  External  Erysipelas. — Erysipelas  of  Newly- 
horn  Infants  is  occasionally  met  with,  more  particularly  in  lying-in 
hospitals,  or  in  situations  where  the  mother  and  child  are  exposed  to 
depressing  causes  of  disease.  It  usually  appears  a  few  days  after  the 
birth,  at  first  about  the  abdomen  and  genitals,  and  soon  spreads  over 
the  whole  of  the  body,  being  characterized  by  a  dusky  redness,  which 
rapidly  runs  into  gangrene  of  the  affected  tissues.  It  has  been  supposed 
to  arise  from  inflammation  of  the  umbilical  vein,  or  of  the  umbilicus  itself. 
It  is  extremely  fatal,  owing  to  the  feeble  vitality  of  the  child,  and  pre¬ 
sents  but  few  points  for  treatment;  change  of  air  and  of  nursing,  with 


600 


ERYSIPELAS. 


the  administration  of  a  few  drops  of  spirits  of  ammonia  or  brandy  from 
time  to  time,  being  all  that  can  be  done. 

Erysipelas  of  the  Orbit  may  occur  primarily,  or  as  the  result  of 
extension  of  the  disease  from  the  neighboring  structures.  It  is  danger¬ 
ous,  and  often  fatal  from  encephalitis.  It  commences  with  a  violent 
deep-seated  pain  at  the  base  of  the  orbit;  the  conjunctiva  becomes 
injected  and  ecch3’mosed,  the  e^’elids  are  greatly-  swollen,  red,  and  oede- 
matous  ;  the  e^^eball  protrudes,  and  vision  is  disturbed  or  lost.  Sj^mp- 
toms  of  cerebral  inflammation  now  set  in,  and  the  patient  becomes 
delirious  and  often  sinks  comatose. 

The  Treatment  consists  in  fomentations,  with  earl}^  and  free  incisions 
into  the  orbit,  made  b}"  pushing  a  lancet  flat-wise  between  the  ej’eball 
and  the  orbital  walls,  through  the  inflamed  conjunctiva,  the  e\’elids 
having  previousl^^  been  everted.  In  this  way  inflammatoiy  effusions 
and  perhaps  pus  may  be  evacuated.  Destructive  abscesses  of  the  orbit, 
possibl}^  of  an  erysipelatous  origin,  occasional!}"  occur  in  the  puerperal 
state,  requiring,  when  practicable,  the  free  evacuation  of  the  pus,  in  the 
/  Y-ay  just  mentioned. 

Phlegmonous  Erysipelas  of  the  Head  is  of  very  frequent  occurrence 
from  slight  injuries  or  operations  about  the  scalp  and  face,  more  particu¬ 
larly  in  elderly  people  and  those  of  unhealthy  constitution.  In  this 
form  of  erysipelas  there  are  two  special  sources  of  danger ;  one  is  • 
sloughing  of  the  occipito-frontalis  muscle,  the  other,  inflammation  of 
the  membranes  of  the  brain.  The  occipito-frontalis  rarely  sloughs, 
except  in  cases  of  traumatic  erysipelas  of  the  head.  It  then  loses  its 
vitality  in  consequence  of  the  suppuration  of  the  deep  plane  of  areolar 
tissue  lying  between  it  and  the  cranium,  and  the  encephalitis  occurs 
apparently  by  the  extension  of  the  inflammation  inwards. 

The  Prognosis  of  erysipelas  of  the  head  will  often  greatly  depend 
upon  its  origin — whether  traumatic  or  idiopathic.  When  arising  from 
wound,  it  is  very  commonly  fatal ;  when  it  is  idiopathic,  it  is  very 
seldom  indeed  followed  by  death.  This  diflerence  in  the  termination 
of  the  two  varieties  of  the  disease  is  owing,  I  believe,  to  the  great 
tendency  to  suppuration  and  deep  .sloughing  of  the  scalp  in  cases  of 
wound,  and  the  infrequency  of  this  occurrence  when  there  is  no  breach 
of  surface. 

In  the  Treatment  of  this  affection,  active  means  are  more  frequently 
required  than  in  the  management  of  other  forms  of  erysipelas.  But  in 
very  many,  perhaps  I  may  say  in  most  instances,  the  disease  is  associ¬ 
ated  with  more  or  less  asthenia,  and  then  the  tonic  and  stimulating  plan 
of  treatment  is  attended  by  the  best  results.  With  the  view  of  pre¬ 
venting  sloughing  of  the  muscles,  a  free  crucial  incision  should  be  made 
through  the  scalp  down  to  the  bone  ;  the  head,  of  course,  having  been 
shaved  at  the  onset  of  the  disease.  Bagging  of  matter  must  be  pre¬ 
vented  by  free  counter-openings,  and  the  application  of  pads  and 
bandages,  wherever  it  is  likely  to  occur.  However  much  the  scalp 
may  be  undermined,  or  the  bones  of  the  cranium  exposed,  adhesion 
usually  takes  place,  and  the  vitality  of  the  parts  is  preserved. 

Phlegmonous  Erysipelas  of  the  Lips  and  Side  of  the  Face  and  Neck, 
of  a  peculiarly  fatal  character,  occasionally  occurs  in  young  people  other¬ 
wise  apparently  healthy.  It  begins  with  a  pimple,  bleb,  or  vesicle 
on  the  lips  or  nose.  This  is  occasionally  attributed  to  the  sting  of  some 
insect,  or  possibly  to  inoculation  from  a  carrion-fly.  It  is  hot,  painful, 
and  itching  ;  from  this,  as  from  a  focus  of  mischief,  the  disease  spreads 
rai^idly,  usually  involving  one  side  of  the  face  only.  The  parts  become 


ERYSIPELAS  OF  THE  PUDENDA. 


601 


brawny,  red,  and  purplish,  greatly  swollen,  and  painful.  The  constitu¬ 
tional  disturbance  is  very  great.  Irritative  fever,  rapidly  assuming 
a  low  form,  sets  in  ;  and  death  commonly  results  in  from  fortj^-eight 
hours  to  six  days,  recovery  rarel}^  occurring.  This  disease  has  some 
resemblance  to  malignant  pustule,  but  never  runs  into  suppuration 
or  slough.  Death  results,  apparently,  from  direct  poisoning  of  the 
system  ;  and  treatment  has  little  effect  in  staying  the  progress  of  this 
terrible  malady.  Dietetic  stimulants,  strong  support,  and  tonics  are 
indicated.  Free  incisions  might  be  of  service,  but  the  situation  affected 
prevents  the  possibility  of  their  employment.  . 

Diffuse  Cellulitis  of  the  Submaxillary  Region  has  been  specially 
described  by  Bickersteth.  After  exposure  to  heat  and  cold,  great  inflam¬ 
matory  swelling  rapidl}’’  sets  in  at  the  forepart  of  the  neck  and  under  the 
angle  of  the  jaw;  these  parts  become  diffusedl}'  brawny;  unless  relief 
be  afforded,  death  will  rapidly  ensue  from  suffocation,  the  disease 
spreading  to  the  root  of  the  epiglottis,  and  producing  oedema  glottidis. 

The  Treatment  consists  in  making  a  free  incision  in  the  mesial  line, 
from  the  chin  to  the  os  h^^oides,  through  the  inflltrated  parts,  from 
which  a  thin  dark  serum,  but  no  pus,  will  be  seen  to  exude.  The 
incision  must  be  carried  to  a  depth  of  two  inches  or  more  towards  the 
base  of  the  tongue,  keeping  carefully  to  the  middle  line,  until  the  whole 
of  the  brawn}"  infiltration  has  been  divided. 

Drysij^elas  of  the  Scrotum,  the  “  inflammatory  oedema,”  so  well 
described  by  Liston,  is  of  frequent  occurrence,  as  the  result  of  wounds, 
ulcers,  and  other  sources  of  irritation  in  this  neighborhood.  The  scro¬ 
tum  swells  to  a  large  size,  being  uniformly  red,  but  with  a  semi-transpa¬ 
rent  glossy  appearance,  pitting  readily  on  pressure,  and  feeling  somewhat 
soft  and  doughy  between  the  fingers  ;  the  integuments  of  the  penis  are 
also  greatly  swollen  and  oedematous,  and  sometimes  the  inflammation 
extends  to  the  areolar  tissue  of  the  cord.  The  chief  characteristic  of 
this  form  of  erysipelas  is  its  tendency  to  run  into  slough  without 
any  previous  brawny  or  tense  condition  of  the  parts ;  the  dartos 
becoming  so  distended  with  sero-plastic  fluid  that  the  circulation 
through  it  is  arrested,  and  its  tissue  loses  its  vitality.  When  an 
incision  is  made  into  it  in  this  state  it  scarcely  bleeds,  and  the  sides  of 
the  wound  present  a  yellowish-white  gelatinous  appearance. 

The  Treatment  of  erysipelas  of  the  scrotum  consists  in  making  a  free 
incision  about  four  inches  in  length  from  behind  forwards  on  each  side 
of  the  septum,  taking  care,  of  course,  not  to  go  so  deep  as  to  w-ound 
the  testes  ;  the  part  must  then  be  supported  on  a  pillow,  and  well 
poulticed  and  fomented.  If  this  incision  be  not  made  at  once,  a  great 
part  or  even  the  whole  of  the  scrotum  may  slough  away,  leaving  the 
testes  and  cord  bare  ;  in  these  unpleasant  circumstances,  however,  the 
parts  will  often  with  great  rapidity  cover  themselves  with  a  new  integu¬ 
ment.  The  oedema  of  the  penis  usually  subsides  of  itself,  or  after 
making  a  few  punctures  in  it ;  should  its  integuments,  however,  threaten 
to  slough,  a  free  incision  must  be  made  into  it,  or  the  prepuce  be  slit  up. 

Erysipelas  of  the  Pudenda  is  occasionally  met  with  in  ill-fed 
unhealthy  children  in  whom  cleanliness  is  neglected.  The  parts  become 
a  dusky  or  livid  red,  swell  considerably,  and  quickly  run  into  gangrene, 
which  spreads  up  the  abdomen  or  down  the  nates.  It  may  prove  fatal 
by  inducing  peritonitis  or  exhaustion.  In  the  Treatment,  ammonia, 
bark,  and  the  chlorate  of  potass,  with  good  nourishment,  and  a  little 
wdne,  are  the  principal  means,  at  the  same  time  that  yeast  or  chlori¬ 
nated  poultices  are  applied  locally. 


602 


ERYSIPELAS. 


Erysipelatous  Inflammation  of  the  Fingers^  or,  as  it  is  commonly 
called,  Whitlow  fs,  a  frequent  affection  in  old  and  in  young  people,  either 
occurring  spontaneously  in  cachectic  constitutions,  or  as  an  accompani¬ 
ment  of  renal  disease,  or  arising  from  the  irritation  produced  by 
scratches,  punctures,  or  the  inoculation  of  the  part  with  poisonous  or 
putrescent  matters.  It  is  most  common  in  the  spring  of  the  year, 
when,  indeed,  at  times  it  appears  to  be  epidemic. 

That  whitlow  is  truly  an  erysipelatous  affection  of  the  fingers,  appears 
to  be  the  case  for  the  following  reasons :  1.  The  causes,  whether  of  season, 
infection,  or  local  irritation,  are  the  same  in  both  affections.  2.  The  con¬ 
stitutional  disturbance  is  alwa3^s  verj’’  severe  for  so  slight  a  disease,  and 
assumes  the  same  character  of  speedy  depression  that  we  observe  in  ery¬ 
sipelas.  3.  The  inflammation  of  the  affected  finger  is  invariabl^^  diffused, 
never  being  bounded  by  adhesion,  but  always  tending  to  terminate  in 
suppuration  and  sloughing.  4.  So  soon  as  the  disease  spreads  beyond 
the  affected  finger,  or  to  the  back  of  the  hand,  it  assumes  a  distinctly 
erysipelatous  appearance  and  character. 

T1  le  inflammation  of  whitlow  is  in  many  cases  confined  to  the  pulp  of 
the  finger,  commencing  in  the  dense  cellulo-fibrous  tissue  forming  this, 
and  often  arising  from  a  very  slight  injury,  as  the  prick  of  a  pin,  a 
splinter,  but  not  unfrequently  without  any  traumatic  cause.  The  part 
becomes  extremely  painful,  hard,  red,  and  swollen  ;  it  then  suppurates 
to  a  limited  extent,  with  some  sloughing  of  the  areolar  tissue.  In  many 
cases  the  ungual  phalanx,  which  is  imbedded  in  the  cellulo-fibrous  digital 
pulp,  necroses  when  this  sloughs.  There  is  usually  some  inflammation 
of  the  lymphatics  of  the  arm;  and  not  unfrequently  a  good  deal  of  con¬ 
stitutional  fever  and  irritation  is  present. 

In  the  more  severe  cases  of  whitlow,  the  inflammation,  which  is  of  an 
excessively  painful  character,  owing  probably  to  the  tension  of  the  parts, 
extends  to  the  sheaths  of  the  tendons,  and  then  constitutes  an  affection 
that  is  fraught  with  danger  to  the  utility  of  tlie  finger  or  hand.  The 
whole  finger  swells  considerably,  becomes  red  and  tense,  with  much  throb¬ 
bing  and  shooting  pain;  the  inflammation  rapidl^^  extends  to  the  back 
of  the  hand,  Avhich  becomes  puffy,  red,  and  swollen,  presenting  the  ordi¬ 
nary  characters  of  erysipelas.  Although  the  palm  be  greatl}''  swollen,  it 
usually  preserves  its  natural  color,  or  becomes  of  a  dull  white,  owing  to 
the  greater  thickness  of  its  cuticle.  Pus  rapidly  forms,  both  in  the  finger 
and  liand,  and,  finding  its  waj^  into  the  sheaths  of  the  tendons,  spreads 
up  the  forearm  under  the  annular  ligament.  There  is  usuall^^  no  fluctua¬ 
tion  to  be  felt  in  the  finger,  even  though  pus  may  have  formed,  but  in 
other  parts  of  the  hand  it  may  readily  be  detected  in  the  usual  way.  In 
tliese  cases  there  is  always  much  sloughing  conjoined  with  the  suppura¬ 
tion  ;  the  areolar  tissue  of  the  finger  and  hand,  the  tendons  of  their 
sheaths,  and  the  palmar  fascia  being  all  more  or  less  implicated.  In  some 
cases  the  end  of  the  finger,  as  far  as  the  first  phalangeal  joint  or  the  mid¬ 
dle  of  the  second  phalanx,  falls  into  a  state  of  gangrene  and  has  to  be 
separated.  In  many  cases  the  joints  of  the  fingers  are  destroyed,  and 
the  phalanges  necrose;  or,  if  this  do  not  happen,  the  tissues  of  the  part 
may  be  so  matted  together,  as  the  result  of  sloughing  and  suppuration, 
that  rigid  and  contracted  fingers,  or  a  stiff  and  comparatively  useless 
hand,  may  be  permanentl}"  left.  Whitlow  affecting  the  little  finger  or 
thumb  is  much  more  likely  to  cause  suppuration  in  the  common  sheath 
of  the  flexor  tendons  than  when  it  occurs  in  any  of  the  other  fingers. 
This  is  due  to  the  fact  that  the  synovial  sheaths  of  the  flexor  tendons  of 


INTERNAL  ERYSIPELAS. 


603 


the  thumb  and  little  finger  communicate  with  the  common  sheath,  w^hile 
those  of  the  three  other  fingers  do  not. 

In  the  Treatment^  the  patient  should  be  well  purged,  and  kept  upon  a 
strictly  antiphlogistic  plan  during  the  earl}"  stages.  At  the  same  time 
the  inflamed  finger  should  be  freely  leeched,  and  then  alternately  poul¬ 
ticed  and  soaked  in  very  hot  water,  for  twentj^-four  or  fortj’-eight  hours, 
being  kept  during  the  wdiole  of  this  time  in  an  elevated  position.  In  this 
wa}"  the  inflammation  ma}’’  be  sometimes  cut  short  at  its  onset ;  should 
it,  however,  continue  to  increase,  the  finger  becoming  hard,  with  much 
throbbing,  a  free  longitudinal  incision  must  at  once  be  made  along  each 
side  of  it,  so  as  to  relieve  tension  and  prevent  sloughing;  this  procedure 
should  never  be  omitted,  on  account  of  the  importance  of  the  preserva¬ 
tion  of  the  full  utility  of  the  part.  Local  anmsthesia  of  the  finger  may 
be  produced  by  the  ether  spra3\  The  incision  is  best  made  from  the 
proximal  towards  the  distal  end  of  the  finger,  so  that,  if  the  i:>atient 
attempt  to  withdraw  the  hand  during  the  operation,  he  w’ill  rather  facili¬ 
tate  the  cut  being  made  than  otherwise.  In  making  these  incisions,  the 
sheaths  of  the  tendons  should,  if  possible,  be  avoided ;  if  they  be  opened, 
the  tendons  will  probably  slough,  and  the  finger  be  left  in  a  permanently 
extended  and  rigid  state.  The  finger  must  then  be  well  soaked  in  hot 
water,  and  poulticed.  In  this  wa}^  the  inflammation  may  be  arrested, 
and  sloughing  happilj’  prevented;  should,  however,  matter  have  formed, 
this  must  be  let  out  as  it  accumulates,  and  all  hardened  and  sodden 
cuticle  peeled  from  the  part.  The  dead  and  sodden  cuticle  resulting 
from  the  fomentation  and  poulticing,  should  be  cut  awaj'  with  scissors, 
as  it  frequently"  seriously"  interferes  with  the  exit  of  the  discharges  and 
sloughs.  After  the  opening  has  been  made,  and  any  slough  which  may^ 
have  formed  has  come  away",  it  not  unfrequently  happens  that  a  large 
and  fungoid  granulating  mass  sprouts  up;  this  will,  however,  gradually" 
subside,  as  the  swelling  of  the  finger  goes  down  and  the  inflammation 
abates.  If  the  nail  become  loosened,  it  had  better  be  removed,  as  it  may 
otherwise  keep  up  irritation;  it  must  not,  however,  be  torn  off  if  adhe¬ 
rent,  but  merely  scraped  and  cut  away  so  far  as  it  is  loose.  When  the 
whole  of  a  finger  is  affected,  the  hand  should  be  placed  on  a  pasteboard 
splint  so  soon  as  the  inflammation  has  been  somewhat  subdued,  lest  con¬ 
traction  of  the  affected  finger  ensue,  which  may  eventually  extend  to  the 
neighboring  ones. 

When  the  joints  are  implicated,  destruction  of  the  cartilages  commonly 
ensues;  yet,  by"  position,  and  rest  on  a  splint,  a  tolerably"  useful  though 
stiffened  finger  may"  be  retained.  When  the  bones  are  implicated,  some 
operative  procedure  usually  becomes  eventually"  necessary-.  If  the  ungual 
phalanx  alone  be  necrosed,  it  may"  be  excised  through  an  incision  on 
the  palmar  side  of  the  finger,  the  pulp  and  nail  being  left ;  in  this  way"  I 
have  often  preserved  a  finger  that  must  otherwise  have  been  removed. 
Amputation  of  the  finger  at  the  metacarpo-phalangeal  articulation  will 
usually-  be  required  when  the  second  or  proximal  phalanges  are  involved  ; 
though  here  partial  excision,  by-  cutting  and  scraping  away"  the  diseased 
bone,  may  sometimes  be  usefully"  done.  During  the  later  stages  of  these 
affections,  tonics,  good  diet,  and  stimulants  will  be  required  for  the 
re-establishment  of  the  health. 

INTERNAL  ERYSIPELAS. 

By  Internal  Erysipelas  we  mean  those  forms  of  diffuse  inflammation 
which  affect  the  Mucous  or  Serous  Surfaces,  or  the  Lining  Membrane  of 
Arteries,  Veins,  and  Lymphatics. 


604 


ERYSIPELAS. 


Erysipelas  of  Mucous  Surfaces. — The  mucous  surhxce  that  is 
chiefly  affected  by  this  disease  is  that  covering  the  fauces,  the  pharynx, 
or  the  larynx. 

Erysipelas  of  the  Fauces  may  occur  in  consequence  of  the  disease 
spreading  from  the  head  and  face  to  these  parts;  or  it  may  commence  as 
a  primary  affection,  occurring  perhaps  at  the  same  time  that  the  rash 
appears  on  the  cutaneous  surface  of  some  distant  part  of  the  body. 
When  the  fauces  are  erysipelatous,  they  present  a  bright  crimson  or 
scarlet  color,  with  some  swelling  and  thickening  of  the  soft  palate  and 
uvula:  the  patient  also  most  commonly  has  some  huskiness  or  complete 
loss  of  voice,  and  occasion all}^  some  croup}-  symptoms.  At  the  same 
time  there  is  a  good  deal  of  low  constitutional  fever,  with  a  pungent  hot 
skill  and  a  quick  pulse.  •  This  form  of  erysipelas  is  peculiarly  conta¬ 
gious,  and  occurs  not  unfrequently  in  the  attendants  of  those  who  are 
laboring  under  some  of  the  other  varieties  of  the  disease  ;  of  this  I  have 
seen  numerous  instances.  In  many  cases,  also,  it  is  epidemic,  spreading 
through  a  house  and  affecting  almost  every  inmate. 

Treatment. — The  best  results  are  obtained  by  sponging  the  inflamed 
parts  freely  with  a  strong  solution  of  the  nitrate  of  silver :  and,  if  there 
be  much  constitutional  depression,  by  administering  full  doses  of  am¬ 
monia,  with  camphor  or  bark.  Should  the  disease  go  on  to  sloughing, 
constituting  some  one  of  the  forms  of  “putrid  sore  throat”  (which  not 
unfrequently  happens),  the  mineral  acids  and  bark,  with  chlorinated 
port-wine  gargles,  and  the  brandy-and-egg  mixture  for  support,  will  be 
found  most  useful.  In  many  cases,  this  disease  continues  limited  to  the 
palate  and  fauces ;  but  in  others  it  extends  upwards  or  downwards.  It 
may  extend  upwards  through  the  nares,  out  of  the  nostrils,  and  thus 
spread  over  the  face  and  head.  It  may  extend  downwards,  affecting 
the  gastro-intestinal  membrane,  or,  more  frequently,  implicating  the 
larvnx. 

Er'ysipelatous  Laryngitis.^  as  described  by  Ryland,  Budd,  and  others, 
is  extremely  dangerous.  The  inflammation,  commencing  in  the  fauces, 
rapidly  spreads  to  the  mucous  membrane  and  loose  submucous  areolar 
tissue  external  to  and  within  the  larynx,  giving  rise  to  extensive  oede- 
matous  infiltration  with  sero-plastic  fluid,  which,  by  obstructing  the  rima 
glottidis,  may  readily  suffocate  the  patient.  In  consequence  of  this 
special  tendency  to  oedema,  the  disease  has  by  many  writers  been  termed 
“  cedematous  laryngitisT  After  death,  the  submucous  areolar  tissue  of 
the  fauces,  that  about  the  base  and  frsena  of  the  epiglottis,  and  especially 
that  which  covers  the  posterior  part  of  the  larynx,  will  be  found  to  be 
distended  with  serum  or  a  sero-puriform  fluid.  Idiis  infiltration  occupies 
the  rima  of  the  glottis,  and,  extending  into  the  interior  of  the  larynx, 
gives  rise  to  such  swelling  that  its  cavity  is  nearly  obliterated.  Great 
as  the  swelling  may  be,  however,  in  all  these  parts,  it  never  spreads 
below  the  true  vocal  cords.  This  fact,  which  is  very  important,  is  ex¬ 
plained  by  the  mucous  membrane  coming  closely  into  contact  with, 
and  being  adherent  to,  the  fibrous  tissue  of  which  these  are  composed, 
without  the  intervention  of  any  submucous  areolar  tissue.  The  progress 
of  this  cedematous  inflammation  of  the  mucous  membrane  and  loose 
submucous  tissue  in  these  situations,  is  often  amazingly  rapid,  the  swelling 
being  sufficient  to  induce  suffocation  at  the  end  of  thirty-six  or  forty- 
eight  hours,  or  even  sooner.  If  the  patient  be  not  carried  off  in  this 
way,  there  will  be  a  great  tendency  to  suppuration  and  sloughing  of  the 
affected  tissues,  leading  perhaps  eventually  to  death  from  absorption  of 
pus  and  low  constitutional  fever. 


ERYSIPELAS  OF  THE  SEROUS  MEMBRANES. 


605 


The  Symptoms  of  this  alfection  are  strongly  marked.  The  patient, 
after  being  attacked  with  erysipelas  of  the  fauces,  attended  by  some  diffi¬ 
culty  and  pain  in  deglutition,  and  huskiness  of  the  voice,  is  seized  with 
more  or  less  difficulty  in  breathing,  coughs  hoarsely  and  with  a  croupy 
sound,  and  complains  of  tenderness  under  the  angles  of  the  jaw  and 
about  the  larynx.  The  difficulty  in  breathing  increases,  and  may  speedily 
threaten  the  life  of  the  patient,  giving  rise  to  intense  fits  of  dyspnoea, 
in  one  of  which  he  will  probably  be  suddenly  carried  off.  On  examining 
the  throat  the  fauces  will  not  only  be  observed  to  be  much  and  duskily 
reddened,  but  by  depressing  the  tongue  the  epiglottis  can  be  felt,  and 
perhaps  seen,  to  be  rigid  and  erect. 

In  the  Treatment^  local  means  are  of  the  first  importance.  The  tongue 
having  been  well  depressed,  the  posterior  part  of  the  lar3mx,the  epiglottis, 
and  its  fraena,  must  be  well  scarified  b}^  means  of  a  hernia-knife,  with 
which  this  operation  may  be  most  readily  and  safely  done.  The  patient 
should  then  be  directed  to  inhale  the  steam  of  hot  water,  and  a  large 
number  of  leeches  may  be  applied  under  each  angle  of  the  jaw,  to  be 
followed  by  large  and  hot  poultices ;  at  the  same  time,  the  bowels  must 
be  kept  w’ell  opened,  and  the  patient  treated  b}^  anti-inflammatory  mea¬ 
sures  or  otherwise,  according  to  the  condition  of  the  constitutional  fever. 
Most  frequently,  1  have  found  antimonials  of  great  service  in  the  early 
stages,  followed  later  by  support  and  stimulants.  A  few  hours  after  the 
engorged  tissues  have  been  unloaded  by  scarification,  the  fauces,  phaiynx, 
and  upper  part  of  the  larjmx  should  be  well  sponged  out  with  a  strong 
solution  of  the  nitrate  of  silver  (5i.  to  .$1.)  which  must  be  applied  freel3', 
coagulating  the  mucus,  and  taking  down  the  increased  vascular  action. 
If,  notwithstanding  the  employment  of  these  means,  the  dispnoea  in¬ 
crease,  the  face  becoming  pale,  livid,  and  bedewed  with  a  clamm}’-  per¬ 
spiration,  it  will  be  necessaiy,  to  save  the  patient  from  impending  suffo¬ 
cation,  to  open  the  windpipe.  In  doing  this  I  prefer  laryngotomy,  for 
reasons  that  will  be  mentioned  when  I  come  to  speak  of  the  Diseases  of 
and  Operations  on  the  Air-passages.  In  order,  however,  that  this  ope¬ 
ration  ma}'  be  successful,  it  must  not  be  too  long  dela3'ed,  and  should 
not  be  looked  upon  as  a  last  resource  ;  if  it  be  done  in  time  (and  time 
in  these  cases  is  most  precious,  owing  to  the  rapid  progress  of  the  dis¬ 
ease),  the  patient’s  life  ma3"  probably  be  saved;  but,  if  it  be  deferred  too 
long,  congestion  of  the  lungs  will  come  on,  the  blood  will  cease  to  be 
properly  arterialized,  and  the  patient  will  sink  from  slow  asph3’xia,  even 
though  air  be  at  last  freel3^  admitted.  If  the  patient  survive  to  the  stage 
of  sloughing,  chlorinated  gargles,  bark,  and  support  must  be  our  chief 
reliance. 

Erysipelas  of  the  Serous  Membranes  is  of  common  occurrence 
in  surgical  practice,  being  frequently  met  with  in  the  arachnoid  and 
peritoneum.  These,  like  all  other  serous  membranes,  are  liable  to  two 
distinct  forms  of  inflammation  :  one,  which  is  sthenic,  having  a  tendency 
to  the  formation  of  plastic  l3^mph  ;  the  other,  which  is  diffuse  or  erysipe¬ 
latous,  being  always  accompanied  by  the  exudation  of  aplastic  unor- 
ganizable  fibrine. 

Erysipelatous  or  Diffuse  Arachnitis  commonly  occurs  as  a  conse¬ 
quence  of  injuries  of  the  head  and  erysipelas  of  the  scalp.  There  are 
iisuall3’’  a  flushed  countenance,  bright  staring  eyes,  low  muttering 
delirium,  followed  by  a  comatose  condition,  and  rapidly  terminating  in 
death ;  the  constitutional  symptoms  are  those  of  low  irritative  fever. 
On  examination  after  death,  the  arachnoid  and  pia  mater  are  found 
greatly  injected  with  blood,  forming  a  close  red  net-work  of  vessels  over 


606 


PYEMIA. 


the  surface  of  the  brain ;  the  substance  of  which  is  usually  somewhat 
injected,  the  ventricles  being  distended  with  a  reddish-colored  serum.  If 
examined  at  a  later  period  in  the  disease  than  this,  the  inflamed  arach¬ 
noid  is  found  to  be  covered  wdth  a  laj’er  of  opaque  puriform  lymph,  of  a 
greenish-yellow  color  and  slimy  consistence. 

Erysipelatous  or  Diffuse  Pe7'itonitis  is  not  unfrequently  met  with  in 
aged  and  cachectic  subjects  after  the  operation  for  hernia,  or  as  a  con¬ 
sequence  of  various*  diseases  and  injuries  of  the  pelvic  or  abdominal 
organs.  The  symptoms  are  often  of  a  latent  character,  the  disease 
being  chiefl}^  indicated  b}^  obscure  pain  diffused  over  the  abdomen  with 
tenderness  on  pressure,  an  anxious  depressed  countenance,  and  a  small 
and  rather  hard  pulse.  There  ma}^  be  heat  of  skin  ;  but  it  is  a  peculiar 
feature  of  this  form  of  the  disease  that  the  patient  may  die  without  any 
elevation  of  the  temperature  of  the  bod^”.  On  examination  after  death, 
the  subperitoneal  areolar  tissue  is  found  injected,  the  peritoneum  opaque 
in  parts,  coA’^ered  with  filmy  patches  of  grayish  lymph,  and  usually  con¬ 
taining  a  largish  quantity  of  opaque  dirty-looking  turbid  fluid,  mixed 
Avith  shreds  and  flocculi  of  lymph.  This,  though  closely  resembling  pus 
in  appearance,  is  serum  with  lymph  intermixed,  and  is  peculiarly  acid, 
acrid,  and  irritating.  It  is  this  form  of  peritonitis  that  is  especially 
dangerous  to  dissectors  ;  inoculation  of  the  Angers  with  any  of  this  fluid 
being  often  productive  of  the  most  serious  and  even  fatal  consequences. 

Erysipelatous  Inflammation  of  the  Linmg  Membranes  of  the  Vascular 
System  will  be  discussed  Avhen  we  come  to  consider  diseases  of  these 
parts. 


CHAPTER  XXXIII. 

PYAEMIA. 

The  term  Pyaemia  is  applied  to  a  group  of  pathological  conditions, 
which,  arising  in  somewdiat  similar  circumstances,  and  running  for  the 
most  part  similar  courses,  AV’ere  until  recently  considered  to  constitute  a 
single  AA'ell  defined  affection  dependent,  as  was  supposed,  upon  the  ad¬ 
mixture  of  pus  with  the  blood,  hence  the  name  given  to  it.  This  disease 
(for  it  will  be  found  conA^enient,  though  not  strictly''  correct,  to  look 
upon  the  members  of  this  group  as  constituting  but  one  affection)  is 
closely  allied  in  cause  and  in  character  to  some  of  the  lowest  and  Avorst 
forms  of  erysipelas  and  diffuse  inflammation,  AAuth  which  indeed  it  is 
commonly  associated,  and  to  which  it  i)resents  great  similarity  in  its 
causes,  symptoms,  and  effects. 

Causes. — Like  erysipelas,  pyaemia  commonly  occurs  at  those  seasons 
of  the  year,  and  under  those  atmospheric  conditions,  in  which  diseases 
of  a  low  type  are  prevalent.  There  is  no  more  common  or  certain  cause 
of  its  production  than  the  OA'ercrowTling  of  patients  suffering  from 
suppurating  Avounds  in  hospitals  ;  and  it  is  in  unhealthy  and  cachectic 
constitutions  that  it  usually  manifests  itself  It  is  more  common  in 
adults  and  elderly  people  than  in  children ;  but,  though  it  is  least  fre¬ 
quently  met  with  during  the  earlier  periods  of  life,  it  may  make  its 
appearance  at  any  age.  Yery  young  children  and  even  infants  may  be 
attacked  by  it. 


CAUSES  OF  PYEMIA. 


607 


P3’9emia  is  a  very  common  cause  of  death  after  operations  and  severe 
injuries,  especiall}^  in  hospitals  that  are  situated  in  large  towns,  or  that, 
however  well  situated,  are  overcrowded.  It  is  disposed  to  all  condi¬ 
tions  of  life,  either  before  or  after  oj^erations  or  injuries,  that  tend  to 
impair  the  health,  to  lower  the  strength,  and  to  induce  an  unhealth}" 
state  of  the  blood,  such  as  habitual  want  of  fresh  air,  overcrowding  in 
working  or  in  sleeping  apartments,  and  insufficient  or  improper  nour¬ 
ishment.  Of  all  these  causes,  overcrowding  is  undoubtedly  the  most 
frequent  and  the  most  fatal;  more  particular!}"  is  overcrowding  of 
patients  injurious  if  there  be  many  suppurating  wounds  under  the  same 
roof  That  pyaemia  is  the  result  of  the  faulty  hygienic  conditions  just 
alluded  to,  viz.,  want  of  pure  air,  overcrowding,  and  insufficient  and 
unwholesome  diet,  is  evident  from  the  fact  of  its  being  rife  and  most 
destructive  where  those  causes  of  diseases  prevail,  as  amongst  the 
poorer  classes  of  all  large  and  densely  peopled  towns;  while  in  the 
purer  air  of  country  districts,  or  in  private  practice  amongst  the 
wealthier  classes,  it  is  rarely  met  with.  It  is  one  of  those  causes  of 
death  after  operations  that  might  and  ought  to  be  prevented ;  and 
wherever  it  is  frequent,  we  may  be  sure  either  that  the  constitutions  of 
the  patients  are  peculiarly  deteriorated,  or  else  that  the  hygienic  condi¬ 
tions  to  which  they  are  exposed  after  the  injury  or  operations  are  pecu¬ 
liarly  faulty.  That  it  may  be  prevented,  has  been  abundantly  proved  by 
the  experience  gained  in  the  Franco-German  war  of  1870.  In  that  great 
struggle,  the  fact,  which  had  been  previously  well  known  to  all  scientific 
Surgeons,  was  established  beyond  all  possibility  of  cavil,  that  the  dan¬ 
ger  of  pyaemia  increased,  cseteris  paribus^  in  proportion  as  w’ounded 
patients  were  closely  crowded,  so  that  the  atmosphere  surrounding 
them  became  contaminated  by  morbid  exhalations  from  suppurating 
wounds.  It  was  found  in  numerous  instances  that,  among  the  great 
mass  of  the  wounded,  pyaemia  was  developed  among  those  who  were 
aggregated  within  the  walls  of  hospitals  or  regular  buildings,  such  as 
churches,  barns,  school-houses,  and  conservatories,  W"hich,  though  clean 
and  airy,  did  not  admit  of  thorough  ventilation;  while  it  was  almost,  if 
not  entirely,  unknown  among  soldiers  of  exactly  the  same  class  who 
were  treated  for  their  wounds  in  hastily  constructed  open  and  draughty 
huts.  Indeed,  there  is  no  fact  better  established  in  surgery,  than  that 
pyaemia  is  tlie  invariable  result  of  the  aggregation  of  the  wounded,  and 
^  that  its  development  may  be  prevented  at  any  time  by  reference  to  the 
cubic  space  allotted  to  each  patient.  As  tliis  is  diminished,  so  the 
disease  Increases;  and  this,  cseter is  paribus^  in  an  exact  ratio. 

Pyaemia  is  never  idiopathic  or  primary,  but  either  occurs  subsequently 
to  an  injury  or  wound  of  some  kind,  by  which  inflammation  is  excited, 
which  has  in  most  cases  reached  the  stage  of  suppuration  before  the 
pyaemic  symptoms  come  on ;  or  it  appears  in  connection  with  some  low 
form  of  specific  suppurative  inflammation.  Thus  we  see  boils,  carbun¬ 
cles,  diflfused  abscess,  erysipelas  of  the  skin,  or  erysipelatous  inflam¬ 
mation  of  the  veins  or  absorbents,  precede  and  lead  to  its  occurrence. 
Pyaemia  is  especially  apt  to  occur,  if  decomposing  pus  be  confined  deeply 
amongst  the  tissues  and  unable  to  get  a  ready  outlet.  Wounds  of  veins, 
of  bones,  and  of  joints,  are  the  injuries  that  are  especially  apt  to  be 
followed  by  this  disease ;  and  in  the  puerperal  state  it  is  often  met  with, 
probably  as  the  result  of  uterine  phlebitis. 

Phenomena. — Pyaemia  is  characterized  especially  by  two  series  of 
phenomena;  1.  A  peculiar  train  of  Constitutional  Symptoms  attended 
by  a  state  of  great  depression  of  the  powers  of  the  system  ;  2.  The 


608 


py^MiA. 


formation  of  Abscesses  in  various  parts  of  the  bod3^  It  ma}’-  be  acute, 
subacute,  or  chronic.  Most  usually  the  disease  is  subacute,  and  often 
chronic.  Whatever  form  it  may  assume,  the  symptoms  are  essentially 
the  same,  differing  only  in  degree. 

1.  Symptoms. — The  characteristic  symptoms  of  pj^semia  consist  of  a 
sudden  and  severe  rigor,  accompanied,  perhaps  even  preceded,  by  a 
great  rise  in  the  temperature  of  the  bod}’,  and  followed  by  profuse  and 
exhausting  sweating. 

The  invasion  of  the  disease  is  as  follows.  During  the  period  of  an 
apparently  ordinary  febrile  disturbance,  the  patient  is  seized  with  a 


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rigor,  usually  very  severe  and  prolonged.  This  is  accompanied  by  a 
great  rise  in  the  temperature  of  the  body,  and  is  followed  by  profuse 


TEMPERATURE  IN  PYEMIA. 


609 


sweating,  during  which  the  temperature  falls.  The  temperature  will  rise 
as  hioh  as  10t°  Fahr, 

The  accompanying  Diagrams  (Figs.  211,  212),  for  which  I  am  indebted 
to  Ringer,  who  took  them  from  patients  of  mine,  will  indicate  this  more 
clearly  than  any  description. 


A  single  rigor  only  may  occur,  and  the  disease  pass  off.  But  more 
frequently  the  rigors  are  repeated  at  intervals  of  from  24  to  48  hours ; 
and,  as  the  disease  becomes  established,  they  may  recur  twice  or  oftener 
in  the  24  hours. 

The  temperature  of  the  body  in  p3"9emia  presents  remarkable  and 
characteristic  fluctuations.  It  is  uniformly  higher  than  normal,  but 
rises  above  and  falls  in  its  general  level  in  exact  accordance  with  the 
development  of  the  rigors.  Ringer,  who  has  paid  great  attention  to  this 
subject,  believes  that  the  rise  in  the  temperature  precedes  the  occurrence 
of  the  rigors;  and  he  has  been  able  to  predict  the  approach  of  a  rigor  by 
noting  a  commencing  rise  in  the  thermometer.  It  is  a  remarkable  cir¬ 
cumstance  that  this  actual  and  great  increase  in  the  temperature  of  the 
body  should  coexist  with  a  sensation  of  cold. 

As  the  rigor  subsides  the  patient  breaks  into  a  sweat — first  about  the 
face  and  head,  then  over  the  body.  The  sweats  are  usually  very  pro¬ 
fuse,  the  bedclothes  being  soaked  with  perspiration.  They  are  very 
exhausting  to  the  patient.  As  soon  as  sweating  comes  on,  the  tempera- 
VOL.  I. — 39 


610 


P  Y  J^MIA. 


lure  begins  to  fall,  and  continues  to  decline  until  it  reaches  the  uniform 
level. 

The  heat,  rigor,  and  sweating,  increasing  at  pretty  regular  intervals, 
cause  an  invasion  of  pyaemia  closely  to  resemble  that  of  an  ague  fit. 
And,  indeed,  there  would  appear  to  be  a  close  analogy  between  the  two 
diseases  ;  for,  as  ague  is  the  result  of  blood-poisoning  from  exposure  to 
malarial  influences  and  the  introduction  into  the  s^^stem  of  peculiar  pro¬ 
ducts  of  vegetable  decomposition,  or,  if  Salisbuiy  be  right,  of  vegetable 
organisms  of  low  grade,  so  p3^8emia  is  the  effect  of  contamination  of  the 
blood  b}’  the  absorption  into,  or  the  admixture  with  it,  of  animal  mat¬ 
ters  in  a  state  of  change  that  renders  them  capable  of  exercising  a  toxic 
influence  on  the  bod}^  generall}'. 

After  the  occurrence  and  repetition  of  heat,  rigor,  and  sweating, 
other  changes  begin  to  manifest  themselves. 

Any  open  w’ound  that  may  exist  at  this  time  usually  becomes  foul 
and  slough}^,  and  ceases  to  secrete  healthy  pus ;  but  this  is  by  no  means 
necessarily  the  case,  for  it  may  continue  healthil}’’  granulating  through¬ 
out  the  disease.  The  skin  is  continuously  hot,  and  has  often  a  burning 
pungent  feel.  The  breath  has  that  peculiar  sweetish,  saccharine,  or  fer¬ 
mentative  smell  that  is  commonly  noticed  in  all  febrile  diseases  of  a  low 
type  ;  this  odor  of  the  breath,  and  indeed  of  the  body  generally,  often 
occurs  early  in  the  disease,  and  must  then  be  taken  almost  as  a 
diagnostic  and  certainlj^  as  a'  most  unfavorable  sign.  The  secretions  are 
arrested  ;  the  pulse  is  quick  and  soft  ;  the  face  is  usually  pale,  wdth  a 
veiy  anxious  drawn  look,  but  sometimes  flushed,  and  the  eyes  bright ; 
there  are  hebetude  and  dulness  of  mind,  with  slight  nocturnal  delirium, 
but  perfect  consciousness  on  being  spoken  to.  Rapid  wasting  of  the 
body  sets  in  about  this  period ;  patches  of  erratic  erythema  frequently 
make  their  appearance  on  the  surface ;  and  the  skin  assumes  a  dull 
sallow,  and  earthy,  or  a  bright  yellow  icteric  tint,  which  may  extend 
even  to  the  conjunctivte.  The  symptoms  now  indicate  an  extreme 
depression  of  the  vital  powers  ;  the  pulse  becoming  small  and  fluttering, 
the  tongue,  which  has  deen  dry,  becoming  brown,  sordes  being  deposited 
about  the  teeth,  and  low  delirium  supervening.  Usually  from  the  sixth 
to  the  tenth  day,  but  sometimes  earlier,  suppuration  commences  in 
different  tissues,  joints,  and  organs.  Abscess  may  form  in  the  lungs  or 
pleurae  without  cough  or  pain  ;  if  in  the  areolar  tissue,  or  in  the  sub¬ 
stance  of  muscles,  there  is  usuall^^  doughy  swelling,  with  some  redness  ; 
if  in  the  joints,  the  swelling  is  often  considerable,  the,  pain  usually 
intense  and  very  superficial  and  cutaneous,  the  i)atient  screaming  aloud 
with  the  agony.  These  pains,  which  are  chiefly  seated  in  the  knees,  ankles, 
hips,  and  shoulders,  often  simulate  rheumatism  very  closely,  and  have 
been  mistaken  for  that  disease. 

The  progress  of  the  disease  is  usually  from  bad  to  worse,  sometimes 
rapidl}^,  but  at  other  times  not  uninterruptedly  so,  there  being  remis¬ 
sions  and  apparent,  though  not  real,  improvement.  The  patient  rapidly 
wastes,  the  body  becoming  shrunken,  the  muscles  soft,  and  the  skin  gray 
or  sallow,  loose  and  pendulous;  great  debility  also  sets  in.  The  abdo¬ 
men  becomes  tympanitic,  diarrhoea  or  profuse  sweats  come  on ;  pneu¬ 
monia  or  pleuritic  effusions  declare  themselves  ;  delirium,  from  which  the 
patient  is  easil}’  roused,  alternates  wdth  sopor;  and  at  last  he  sinks  from 
exhaustion.  Death  usually  takes  place  about  the  tenth  or  twelfth  day ; 
though  it  ma}'  occur  as  early  as  the  fourth,  or  the  patient  may  linger  on 
for  six  or  seven  weeks. 

In  other  cases  pysemia  occurs  in  a  very  insidious  manner,  without 


FORMATION  OF  PURULENT  DEPOSITS. 


611 


severe  rigor,  but  merely  with  prostration,  and  some  low  fever  of  an  inter¬ 
mittent  kind  ;  after  a  time  the  skin  assumes  a  yellow  tint,  as  do  the  con- 
junctivse.  The  urine  is  very  high  colored,  and  perhaps  the  peculiar  odor 
in  the  breath  or  body  may  be  noticed;  but  the  patient  continues  in  a 
quiet  state,  his  wound  being  clean,  and  suppurating  healthily.  He  gets, 
however,  symptoms  of  low  pneumonia  and  pleurisy,  perhaps  with  pain 
and  fulness  in  one  joint,  where  abscess  forms,  and  then  the  disease  fully 
declares  itself. 

2.  The  Formation  of  numerous  Purulent  Deposits^  “  secondary  or 
metastatic  abscesses,”  as  they  are  often  termed,  is  one  of  the  most 
marked  features  of  pyaemia.  These  abscesses  usually  contain  a  some¬ 
what  thin  and  oily-looking  pus ;  sometimes,  however,  it  is  thick  and 
laudable.  The  moi‘e  oily-looking  fluid,  though  opaque  and  yellow,  and 
closely  resembling  true  pus,  will,  on  microscopic  examination,  be  found 
to  differ  from  this  in  the  absence  of  the  true  nucleated  pus-corpuscles, 
though  it  contains  an  immense  number  of  granular  cells  (Fig.  60).  After 
removal  it  often  forms  a  firm  fibrinous  coagulum.  These  purulent  col¬ 
lections  vary  greatly  in  size  and  in  situation.  The}"  are  found  in  four 
localities,  viz.,  in  the  viscera,  in  the  areolar  and  muscular  structures,  in 
the  serous  membranes,  and  in  the  joints.  They  are  most  frequently  met 
with  in  the  lungs  and  pleurae,  usually  iu  one  pleural  sac  only ;  then  in 
the  joints;  next  in  the  intermuscular  areolar  planes. 

Pyaemic  abscesses  difier  from  ordinary  purulent  collections,  not  only 
in  the  peculiar  character  of  the  pus  that  they  contain,  but  more  particu¬ 
larly  in  the  rapidity  with  which  they  form,  a  few  days  commonly  sufficing 
for  them  to  attain  a  large  size.  This,  with  their  very  widely  spread  cha¬ 
racter,  and  the  insidious  manner  in  which  they  occur,  often  with  few  if 
any  local  signs — the  tissues,  as  it  were,  breaking  down  without  any 
inflammation — constitute  the  distinguishing  features  of  these  collections. 

The  visceral  abscesses  vary  in  size  from  a  pin’s  head  to  a  walnut ;  in 
many  cases  the  organs  affected  are  studded  with  them.  These  collections 
are  most  frequently  met  with  in  the  lungs,  being  seated  at  the  posterior 
part  and  on  the  surface  of  these  organs,  or  in  the  interlobular  fissures ; 
they  are  usually  surrounded  b}^  a  darkly  inflamed  and  condensed  la3^er 
of  pulmonary  tissue,  and  not  unfrequently  the}"  are  seated  in  the  midst 
of  a  large  patch  of  lung  in  a  state  of  low  or  congestive  pneumonia,  or 
the  whole  of  the  posterior  part  of  the  lung  may  be  in  this  condition 
studded  with  small  pytemic  abscesses.  The  organ  that  is  most  frequently 
affected  next  to  the  lung  is  the  liver.  Here,  also,  the  abscesses  are  usu¬ 
ally  small,  numerous,  and  surrounded  by  an  inflamed  or  congested 
areola  of  hepatic  substance.  In  some  cases,  however,  hepatic  pyaemic 
abscess  is  single  and  of  considerable  size,  perhaps  as  large  as  an  orange. 
I  have  seen  purulent  collections  in  the  spleen  ;  but  they  are  rare  here,  in 
comparison  to  the  organs  just  named.  They  may  occur  in  other  organs  ; 
thus  Gamgee  has  on  several  occasions  observed  them  in  the  prostate. 

When  the  pus  is  infiltrated  into  the  areolar  tissue  and  muscles  of  the 
limbs  and  trunk,  it  forms  immense  diffuse  collections  of  a  thin  serous 
matter,  commonly  mixed  with  shreds  of  the  areolar  membrane  of  the 
part,  having  no  boundary  of  limiting  fibrine.  These  collections  are  most 
frequent,  perhaps,  in  the  axilla,  down  the  flank  and  about  the  back,  in 
the  iliac  fossa,  thigh  or  calf,  and  may  either  be 'confined  to  the  subcu¬ 
taneous,  or  extend  to  the  deep  intermuscular,  areolar  planes  in  these 
regions ;  or  they  may  even  form  in  the  muscular  substance  itself,  being 
diffused  between  the  fasciculi,  which  are  softened  and  disintegrated. 
Most  commonly  the  presence  of  these  collections  is  indicated  by  patches 


612 


PYEMIA. 


of  cutaneous  or  erratic  eiysipelas,  and  by  a  dough}^,  oedematous,  and 
bogg3’  state  of  the  superjacent  integuments. 

Accumulations  of  pus  and  deposits  of  lowly  organized  Ij^mph  in  and 
upon  the  serous  and  sjuiovial  membranes  are  veiy  common  ;  the  pleura, 
the  arachnoid,  or  the  peritoneum  may  each  be  thus  affected.  In  the 
pleura  especialh^,  these  accumulations  are  frequent,  and  pyaemic  empj^ema 
will  often  occur  very  suddenly  with  few,  if  an}',  general  symptoms  or 
local  signs  to  indicate  its  presence.  Frequently  some  of  the  joints,  espe¬ 
cially  the  knees  and  shoulders,  become  filled  with  a  thin,  yellow,  puru¬ 
lent  liquid.  These  arthritic  abscesses  are  usually  indicated  by  intense 
pain,  often  cutaneous  or  superficial,  with  fluctuation  and  swelling  in  the 
joint.  Often,  however,  large  accumulations  of  pus  form  suddenly  in 
joints,  without  having  been  preceded  by  pain  or  any  other  sign  of  mis¬ 
chief;  in  these  cases  the  interior  of  the  joint,  though  filled  with  pus, 
remains  tolerably  healthy,  there  being  no  erosion  of  cartilage  or  destruc¬ 
tion  of  ligament,  but  merely  some  inflammatory  injection  of  the  synovial 
membrane. 

Not  only  are  the  appearances  just  mentioned  commonly  met  with  in 
cases  of  death  from  pyaemia,  but  we  And  inflammation  of  the  viscera, 
more  particularly  of  the  brain  and  lungs,  and  not  unfrequently  a  diffused 
erysipelatous  redness  of  some  membranous  surface,  as  of  the  arachnoid 
or  the  gastro-intestinal  mucous  membrane. 

Diagnosis. — The  diagnosis  of  pyaemia  requires  to  be  made:  l,from 
ordinary  Surgical  Fever,  the  Inflammatory  Fever  wdiich  accompanies 
wounds  and  lujuries,  especially  when  severe,  and  Typhoid  Fever ;  2,  from 
Ague  ;  3,  from  Kheumatism. 

1.  The  diagnosis  from  ordinary  Surgical  Inflammatory  Fever  and 
Typhoid  Fever  is  usually  sufliciently  easy,  the  course  of  these  fevers 
being  unbroken  by  severe  rigors,  by  sudden  fluctuations  of  temperature, 
or  by  sw'eats.  These  symptoms,  w’hich  are  characteristic  of  pyaemia,  do 
not  occur  in  these  other  forms  of  febrile  disturbance.  An  ordinary  fever 
may  be  ushered  in  by  a  rigor ;  but  this  is  seldom  so  intense  as  that  which 
marks  pyaemia,  and  certainly  does  not  recur  during  the  attack.  The 
temperature  also  in  ordinary  fevers  is  uniformly  and  continuously  high. 
It  is  not  marked  by  those  sudden  exacerbations,  folio w^ed  by  equally 
rapid  declines,  that  are  so  marked  in  pyaemia.  But  it  must  be  borne  in 
mind  that  a  pyaemic  rigor  may  occur  in  the  midst  of  the  uniform  high 
temperature  of  simple  inflammatory  fever,  indicating  the  development  of 
the  blood-poisoning;  but  then  the  decline  is  only  to  and  not  below  the 
previous  high  level,  and,  unless  the  pyaemia  become  established,  the 
rigor  and  rise  of  temperature  do  not  recur. 

2.  From  Ague  the  diagnosis  would  not  be  easy  in  the  earlier  stages, 
if  the  patient  had  been  exposed  to  malarial  influences  as  w'ell  as  to  the 
ordinary  causes  of  pyaemia,  as  in  a  person  injured  wdiilst  living  in  a 
sw'ampy  country.  But,  in  large  towns,  the  general  absence  of  ague  and 
the  obvious  surgical  causes  of  the  pyaemia  will  render  the  diagnosis  more 
easy.  In  the  later  stages,  the  signs  of  articular  inflammation  and  sup¬ 
puration,  the  secondary  visceral  and  areolar  abscesses,  will  all  tend  to 
clear  up  the  diagnosis. 

3.  From  Rheumatism  it  is  easy  to  make  the  diagnosis  of  pyaemia,  pro¬ 
vided  the  recurrent  rigor  and  other  early  symptoms  have  been  w’ell  and 
strongly  marked.  But  if  these  have  been  somewhat  obscure,  and  if  the 
secondary  articular  implication  be  early  developed,  then  it  may  certainly 
be  difficult  to  determine  the  exact  disease  with  which  the  patient  is 
affected.  But,  independently  of  the  recurrent  rigor,  the  great  prostra- 


PATHOLOGY  OF  PYEMIA. 


613 


tion,  the  early  supervention  of  atonic  symptoms,  the  development  of  the 
visceral  abscesses,  of  areolar  suppuration,  and  of  patches  of  erratic 
erysipelas,  will  establish  the  true  nature  of  the  disease. 

Prognosis. — The  prognosis  in  pyaemia  is  always  bad.  The  disease 
is  dangerous  to  life,  to  health,  and  to  limb.  When  active  acute  p3^aemia 
has  fairly  set  in,  recovery  rarely,  if  ever,  takes  place,  the  patient  usually 
dying  between  the  fourth  and  the  twelfth  days.  One  or  two  pyaemic 
rigors  may  be  recovered  from.  It  is  the  repetition  of  these  attacks, 
followed  by  profuse  sweating,  and  attended  by  extreme  exhaustion,  that 
is  so  fatal.  In  fact,  the  danger  and  the  rapidity  of  the  fatal  termination 
in  any  given  case  will,  cseteris  paribus^  depend  on  the  rapidity  of  the 
recurrence  of  the  rigors  and  their  severity.  ' 

When  the  p3'aemic  attack  is  from  the  first  subacute  or  chronic,  it  may 
be  recovered  from,  usually  after  prolonged  illness,  the  formation  of  nu¬ 
merous  or  large  abscesses,  and  great  and  continued  disturbance  of  the 
general  health. 

In  these  less  active  and  acute  forms  of  pyaemia,  one  joint  is  liable  to 
special  implication,  more  particularly  the  knee,  and  next  the  elbow.  The 
diseased  action  lighted  up  in  it  may  go  on  to  inflammatory  disorganiza¬ 
tion.  Destructive  suppuration  ma3’’  be  set  up  in  it,  and  loss  or  perma¬ 
nent  impairment  of  utility  of  limb  will  be  the  inevitable  result. 

Pathology. — That  the  blood  undergoes  important  changes  in  this 
disease  is  unquestionable,  and  there  are  many  reasons  for  believing  with 
Yirchow,  to  whom  we  are  indebted  for  much  light  on  this  subject,  that 
at  least  three  different  conditions  may  present  themselves ;  which, 
although  probabl3'  coexisting  in  the  majorit3"  of  cases,  yet  are  of  inde¬ 
pendent  origin,  and  may  each  prove  the  sole  existing  cause  of  some 
special  S3unptoms,  which,  taken  together,  constitute  the  disease  called 
pyjemia.  These  tliree  conditions  are — 

1.  An  increase  in  the  number  of  the  colorless  blood-corpuscles,  con¬ 
stituting  the  affection  termed  Leucocytosis^  which  has  been  commonly 
viewed  as  a  proof  of  the  admixture  of  pus  with  the  circulating  fluid. 

2.  The  formation  of  Thrombi^  and  the  changes  which  take  place  in 
them  leading  to  Embolism  or  3Ietastaiic  Deposits. 

3.  An  absorption  of  ichorous  or  putrid  matter,  and  the  commingling 
of  this  with  the  blood-stream,  producing  the  condition  called  Ichorrhde- 
mia  or  Septicaemia. 

It  will  be  desirable  to  consider  these  three  conditions  and  their  conse¬ 
quences  seriatim. 

1.  Leucocytosis.f  or  increase  of  the  white  corpuscles,  with  a  correspond¬ 
ing  increase  in  the  amount  of  fibrine  in  the  blood,  is  dependent  upon  an 
overaction  of  the  l3^mphatic  glands,  arising  from  an  irritation  applied  to 
a  part  freel3^  supplied  with  13'mphatic  vessels.  The  eharacter  of  the 
irritation  has,  however,  an  important  influence  in  determining  the  occur¬ 
rence  of  this  condition;  thus,  an  erysipelatous  or  diffuse  phlegmonous 
inflammation,  affeeting  at  an  early  period  the  lymphatic  vessels  and 
glands,  may  be  expected  to  produce  leucoc3ffosis  far  more  rapidly  and 
certainly  than  a  superficial  inflammation  of  the  skin  due  to  traumatic  or 
other  simple  causes.  In  consequence  of  the  adhesive  and  segregatory 
characters  of  these  white  corpuscles,  they  may  often  be  found,  when 
present  in  considerable  numbers,  to  be  collected  into  masses  or  groups 
attached  to  the  walls  of  the  vein,  thus  giving  rise  to  the  belief  that  they 
are  reall3’  pus-corpuscles,  from  which  indeed  they  are  absolutel3^  indis¬ 
tinguishable,  and  that  they  are  the  products  of  inflammatory  changes  in 
the  W'alls  of  the  vessels.  This  may  be  well  seen  in  any  part  where 


614 


PYJEMIA. 


coagulation  has  taken  place,  the  clot  presenting  a  layer  of  milky  white¬ 
ness  due  to  the  entanglement  of  the  white  corpuscles  in  the  meshes  of 
the  fibrine.  It  cannot  be  doubted  that  any  considerable  increase  in  the 
numbers  of  bodies  possessing  such  marked  powers  of  adhesion,  both  to 
one  another  and  to  the  walls  of  the  vessels,  must  tend  to  diminish  the 
freedom  of  the  circulation  through  the  smaller  vessels  and  capillaries, 
and  thus  facilitate  the  occurrence  of  stasis  in  the  vessels.  This  con¬ 
dition  of  the  blood  seems  to  be  connected  with  a  state  of  general  depres¬ 
sion,  and  a  pallor  or  a  certain  yellowness  of  the  skin.  How  far  it  is 
connected  with  the  formation  of  the  metastatic  and  secondary  abscesses 
characteristic  of  the  true  p^^semic  state,  is  not  yet  determined  ;  although 
the  demonstration  of  the  passage  of  the  white  corpuscles  through  the 
walls  of  the  vessels,  and  their  further  development  into  pus-corpuscles, 
renders  the  view  suflSciently  plausible,  that  some  such  connection  exists. 

2.  The  subject  of  Thrombosis  and  Embolism  is  one  of  the  most  im¬ 
portant  that  can  engage  the  attention  of  the  scientific  Surgeon,  as  upon 
a  full  comprehension  of  the  circumstances  attending  these  processes  will 
in  great  measure  depend  his  knowledge  of  the  pathology  of  this  disease. 

The  Causes  which  lead  to  the  formation  of  a  thrombus  or  clot  in  a 
vessel  are  of  three  kinds,  viz. : — 

a.  Retardation  of  the  blood-stream  ;  due  to  (a)  Diminished  vis  a  tergo ; 
(l3)  Diminished  calibre  of  the  vessel ;  (y)  Interruption  of  its  continuity. 

b.  Changes  in  the  condition  of  the  w'all  of  the  vessel,  or  the  presence 
of  foreign  bodies;  due  to  (a)  Imperfect  nutrition  of  the  wall  of  the  vessel, 
complete  or  incomplete;  (l3)  Injuries  of  the  wall,  or  presence  of  foreign 
bodies. 

c.  Altered  conditions  in  the  blood  itself;  due  to  (a)  Leucocytosis ; 
((3)  Septicaemia. 

A  thrombus  forms  more  frequently  in  a  vessel  of  medium  size  than  in 
one  of  a  veiy  large  or  very  small  calibre;  and,  as  might  be  expected, 
more  frequentlj'-  in  a  vein  than  in  an  artery  of  equal  magnitude.  The 
phenomena  attending  the  formation  of  a  thrombus  in  an  artery  have  been 
already  considered,  and  it  will  therefore  only  be  necessary  here  to  review 
those  results  of  coagulation  in  the  veins  w^hich  are  intimately  connected 
with  the  subject  before  us.  It  will  be  desirable  to  consider  the  infiuence 
of  these  causes  seriatim. 

a.  Diminished  vis  a  tergo  may  result  from  want  of  power  in  the  con¬ 
tractions  of  the  heart,  or  from  interruption  to  the  proper  distribution  of 
the  force,  through  want  of  elasticity  in  the  arteries :  the  current  of  blood 
in  the  veins  thus  fiowing  wfith  less  rapidity,  coagula  are  liable  to  form 
around  the  valves  or  in  any  dilatation  which  may  happen  to  exist. 
Another  very  common  cause  of  retardation  consists  in  the  diminution 
of  calibre  produced  by  the  pressure  of  a  tumor  upon  a  vessel,  or  by 
the  contraction  following  infiammatory  exudation  in  the  substance  of  an 
organ:  examples  of  these  conditions  may  be  frequently  seen  in  the  iliac 
veins  pressed  upon  by  a  pregnant  uterus  or  an  ovarian  tumor,  and  in 
the  vessels  of  a  cirrhotic  liver.  The  most  important  cause,  however,  is 
undoubtedly  the  interruption  of  the  floiu  of  blood  w’hich  follow^s  the 
division  of  a  vein  during  a  surgical  operation.  Several  circumstances 
infiuence  this  result  in  an  important  manner ;  thus,  if  a  vein  be  divided 
immediately  below  the  site  of  a  pair  of  valves,  these  being  closed  by  the 
pressure  from  above,  coagulation  will  take  place  in  the  column  of  blood 
thus  rendered  stationary;  the  clot  may  be  limited  or  may  extend  to  a 
considerable  distance  along  the  vessel,  and  not  unfrequently  small 
isolated  thrombi  form  around  the  valves  of  the  venous  trunks  leading 


THEOMBOSIS. 


615 


from  such  an  occluded  branch.  This  process  has  been  commonly  des¬ 
cribed  as  phlebitis,  the  coagulation  being  viewed  as  secondary  to  the 
inflammatory  changes  in  the  coats  of  the  vessel,  which  usually  ensue, 
sooner  or  later.  These  considerations  offer  a  probable  explanation  of 
the  evil  effects  which  frequently  follow  the  application  of  a  ligature  to  a 
large  venous  trunk;  because,  as  a  large  column  of  blood  is  in  these  cases 
rendered  stagnant,  coagulation  rapidly  sets  in  and  is  not  easily  limited. 

b.  Amongst  the  second  class  of  causes,  inflammation  of  the  coats  of 
the  vessels,  arteritis  and  phlebitis,  formerly  occupied  the  most  promi¬ 
nent  position.  Hunter  described  two  forms,  the  suppurative  and  adhe¬ 
sive;  and  he  considered  that  an  exudation  was  thrown  out  upon  the  surface 
of  the  lining  membrane,  which  acted  as  the  exciting  cause  of  the  throm¬ 
bosis.  This  has,  however,  been  shown  to  be  incorrect.  The  external 
coat  may  become  inflamed,  and  the  muscular  coat  suffers  secondarily 
and  becomes  swollen,  producing  not  onl}^  a  narrowing  of  the  calibre  of 
the  vessel  but  some  irregularity  on  its  inner  surface.  This  may  lead  to 
coagulation;  but,  if  the  inflammatory  action  stop  short  of  suppuration, 
the  vessel  may  even  regain  its  original  condition  without  the  formation 
of  any  clot;  should,  however,  necrosis  of  the  inner  coat  result,  a  throm¬ 
bus  rapidly  forms  upon  tlie  affected  surface,  and  the  vessel  remains  more 
or  less  permanently  occluded.  In  the  great  majorit}'’  of  cases  of 
phlebitis,  however,  the  thrombus  will  be  found  to  have  been  the  cause 
of  the  inflammation,  and  not  to  have  resulted  from  it.  The  deposit  of 
fibrine  which  takes  place  upon  the  roughened  walls  of  a  degenerated 
artery  must  be  considered  as  having  a  protective  influence,  and  as 
tending  to  lessen  the  danger  of  rupture.  The  protrusion  of  foreign 
bodies,  such  as  spicula  of  bone,  or  fragments  of  atheroma  of  fibrine,  may 
give  rise  to  the  formation  of  a  thrombus  at  any  spot,  and  may  be  con¬ 
sidered  under  the  same  head  as  embolism. 

c.  Among  changes  in  the  blood  itself,  which  lead  to  the  formation  of 
thrombi,  those  conditions  already  described  under  the  head  of  leucocyto- 
sis  necessarily  occupy  an  important  position,  as  tending  not  only  to 
diminish  the  rapidity  of  the  flow  in  consequence  of  the  increased  vis¬ 
cosity  of  the  fluid,  but  to  cause  an  increase  in  the  amount  of  coagulable 
material  or  fibrine.  It  is  doubtful  whether  this  condition  alone  would 
suffice  to  produce  coagulation  in  the  vessels ;  it  must,  however,  prove  a 
powerful  predisposing  cause.  It  is  probable,  also,  that  certain  septic 
conditions  of  the  blood  may  tend  to  increase  the  liability  to  coagulation 
in  the  smaller  vessels  and  capillaries  in  consequence  of  altered  or  arrested 
function  of  certain  organs — lungs,  liver,  or  kidneys.  This  is,  however, 
probably  the  least  important  influence  produced  by  septic  conditions  of 
the  blood,  which  seem  rather  to  lead  to  the  softening  and  breaking 
down  of  clots  than  to  their  formation. 

Changes. — A  thrombus,  having  formed,  usually  undergoes  certain 
changes  either  of  a  destructive  or  productive  character,  the  results  being 
classed  as  follows: — 

a.  Changes  in  the  clot  itself  leading  to  organization,  obsolescence,  or 
softening  and  breaking  down ; 

b.  Changes  in  other  parts  due  to  the  formation  of  the  clot,  viz., 
dianges  in  the  walls  of  the  vessel  and  the  establishment  of  the  collat¬ 
eral  circulation;  or  to  the  destruction  of  the  clot. 

The  wall  of  the  vessel  usually  contracts  upon  the  contained  clot,  which 
gradually  shrinks,  becomes  denser,  more  fibrillated,  and  ultimately  pene¬ 
trated  by  vessels.  It  may  subsequently  undergo  calcareous  degenera¬ 
tion,  leading  to  the  formation  of  phleboliths,  not  unfrequently  found  in 


616 


PYJEMIA. 


venous  plexuses.  The  changes  which  end  in  disintegration  produce, 
however,  the  most  serious  results,  leading  to  secondary  hemorrhage  in 
the  case  of  the  arteries,  and  to  blood-poisoning  or  metastatic  deposits 
in  that  of  the  veins.  The  causes  which  lead  to  these  changes  are  some¬ 
what  obscure,  but  are  generally  dependent  upon  bad  hygienic  sur¬ 
roundings  and  septic  or  epidemic  influences.  It  is  remarkable  how 
very  rapidly  large  clots  may  become  disintegrated,  and  be  washed  away 
by  the  blood  stream  in  a  state  of  minute  subdivision,  without  producing 
any  apparent  results.  Should,  however,  the  fragments  be  of  larger  size, 
the  phenomena  of  Embolism  are  produced :  these  effects  have  been  care- 
full}'  studied  b}’^  Yirchow,  to  whose  admirable  researches  science  is 
indebted  for  an  explanation  of  the  results  of  these  processes. 

An  embolon  is  a  solid  body  which  has  entered  the  current  of  circula¬ 
tion.  It  may  consist  of  detached  fragments  of  fibrine,  calcareous  or 
atheromatous  matter,  foreign  bodies,  or  entozoa.  The  effects  which  it 
produces  will  depend  upon  its  size  and  qualities,  and  upon  the  part  of 
the  circulation  into  which  it  may  have  entered.  Thus  it  may  become 
arrested  in  vessels  of  considerable  size,  or  in  the  smallest  arteries 
or  capillaries;  if  it  commences  its  career  within  an  arterial  trunk,  it 
may  become  impacted  in  the  smaller  branches  or  in  the  capillaries  of 
the  sj’stemic  circulation ;  whereas,  if  it  arise  within  a  vein,  it  will  pro¬ 
bably  be  arrested  in  the  branches  of  the  pulmonary  or  the  portal  circu¬ 
lation.  Sometimes,  though  rarely,  the  special  characters  of  the  embolon 
will  enable  the  observer  to  decide  as  to  what  ma}''  have  been  its  origin 
and  course.  It  has  been  doubted  whether  a  fragment  of  notable  specific 
gravity  entering  the  right  side  of  the  heart  from  the  vena  cava  could  be 
propelled  into  the  branches  of  the  pulmonaiy  artery,  and  thus  become 
impacted  in  the  lung;  the  experiments  of  Yirchow  have,  however,  indis¬ 
putably"  proved  the  possibility  of  this  occurrence.  It  is  to  embolism 
that  modern  pathologists  ascribe  the  formation  of  most,  if  not  all,  the 
metastatic  abscesses  found  in  the  lungs  of  patients  who  have  died 
py’mmic;  and  they  consider  that  the  embolon  is  derived  rather  from  the 
destruction  of  pre-existing  thrombi,  than  from  the  entrance  of  true  pus 
into  the  circulation.  Much  attention  has  been  directed  to  the  question 
whether  the  admixture  of  pus  with  the  blood  necessarily  leads  to  the 
occlusion  of  vessels,  and  the  formation  of  capillary  thrombi ;  and  the 
inquiry  can  hardly  be  said  to  be  exhausted.  There  can,  however,  be  no 
doubt  that,  although  the  granular  corpuscles  of  pus  and  blood  are  iden¬ 
tical  in  their  microscopic  characters,  they^  y^et  differ  materially  in  their 
vital  properties,  and  that  the  presence  of  pus  in  any  notable  quantities 
would  lead  to  the  occlusion  of  vessels  and  its  consequences.  The  im¬ 
paction  of  an  embolon  is  indicated  by  the  sudden  occurrence  of  certain 
general  symptoms,  such  as  pain,  numbness,  or  rigor;  but  the  special 
symptoms  will  necessarily  vary  according  to  the  organ  affected;  thus  in 
embolism  of  the  brain  paralysis  will  follow,  whilst  in  the  lung  dyspnoea 
is  most  prominent.  The  immediate  local  effect  of  the  occlusion  of  a 
vessel  is  the  production  of  intense  congestion  in  the  surrounding  parts, 
which  is  usually"  followed  by  hemorrhage  and  the  consequent  production 
of  the  hemorrhagic  infarcts  commonly"  seen  in  these  cases;  the  changes 
which  subsequently  take  place  in  the  part  affected  will  depend  upon  the 
facility"  with  which  the  collateral  circulation  is  established,  and  upon 
this  also  will  depend  in  great  measure  the  maintenance  of  its  vitality\ 
The  appearance  produced  by  these  changes  will  vary  with  the  structure 
of  the  particular  organ  in  which  they  occur,  with  the  character  of  its 
vascular  supplyq  and  with  the  exact  point  at  which  the  body  has  become 


EMBOLISM  AND  SEPTICEMIA. 


617 


impacted.  For  a  full  account  of  these  peculiarities,  the  reader  must 
consult  special  works  on  Pathological  Anatomy. 

It  must  not,  however,  be  supposed  that  the  occurrence  of  embolism 
and  pysemic  abscesses  stand  invariabl3An  the  position  of  cause  and  effect: 
it  is  under  certain  conditions  at  present  imperfectl3’’  understood  that  the 
former  ma^"  give  rise  to  the  latter.  It  is,  indeed,  a  matter  of  common 
occurrence  to  find  hemorrhagic  infarcts  in  the  spleen  or  kidne}^,  or  more 
rarel}"  in  the  liver  or  lung,  without  there  being  an^^  reason  to  suppose 
that  the  patient  had,  at  the  time  of  their  occurrence,  suffered  from  any 
P3^8emic  symptoms.  It  is  highly  probable  that  the  character  of  the 
embolon  itself  has  a  marked  influence  in  determining  the  subsequent 
results,  and  that  simple  mechanical  obstruction  never  gives  rise  to  the 
true  metastatic  abscess  found  in  the  p3’iemic  condition.  P3’0emic  ab¬ 
scesses  may,  moreover,  occur  in  an  organ  having  no  vascular  connection 
with  the  part  in  which  the  original  lesion  exists,  and  in  circumstances 
w’hich  render  it  impossible  to  conceive  that  any  solid  particles  could 
have  passed  from  the  one  to  the  other;  we  must,  therefore,  seek  for 
some  other  cause  to  account  for  their  formation,  and  this  will  lead  us 
to  the  subject  of  blood-poisoning. 

3.  The  third  condition  which  is  present  in  many  cases  of  pymmia,  and 
which  is  probably  the  active  cause  of  man3'  of  the  s3"mptoms,  is  that  of 
blood-poisoning,  Tchorrhaemia  or  Septicaemia^  due  to  the  absorption  of 
ichorous  or  putrid  matter  and  its  entrance  into  the  circulation.  That  this 
is  a  condition  actually  present  in  man3’'  cases  cannot  be  doubted ;  the 
ad3mamic  or  t3’phoid  character  of  the  symptoms,  and  the  appearance  of 
the  blood  after  death,  present  unmistakable  evidence  of  this  fact.  The 
question,  however,  of  chief  interest  in  connection  with  this  subject,  is 
the  mode  in  which  this  condition  is  produced  ;  whether  it  be  the  result 
of  the  absorption  of  putrid  matter  from  the  wound  itself,  or  of  the  soft- 
enino:  and  breakino:  down  of  coaoula  formed  within  the  veins,  or  whether 
it  be  of  the  nature  of  a  ferment  which  exists  in  the  surroundino;  atmo- 
sphere  and  is  absorbed  through  the  lungs.  Many  arguments  ma3"  be 
advanced  in  favor  of  each  of  these  propositions  ;  in  fact,  it  is  highly 
probable  that  the  condition  ma3'  be  established  in  an3’'  of  these  wa3"s  ; 
thus,  in  favor  of  the  atmospheric  tlieoiy,  ma3’  be  urged  the  fact  that  the 
disease  occurs  not  unfrequentl3'  in  patients  who  have  nearh"  recovered, 
wdiose  wounds  are  reduced  to  a  minimum,  and  whilst  these  appear  to  be 
progressing  favorabl3\  On  the  other  hand,  the  first  sign  of  the  danger 
ma3^  appear  in  the  changes  which  take  place  in  the  wound  itself.  It  was 
long  maintained,  and  as  strenuously  denied,  that  pus-corpuscles  may 
enter  the  circulation  b3''  direct  absorption  from  a  suppurating  surface  ; 
and,  although  there  is  no  evidence  that  this  ever  does  occur,  yet  the  dis¬ 
covery  of  the  migration  of  the  white  blood  corpuscles  through  the  walls 
of  the  smaller  vessels,  and  their  transformation  into  pus,  would  render 
this  view  possible  at  least.  The  theories  advanced  at  various  times  hy 
Hunter,  Arnott,  Berard,  and  Sedillot,  which,  taking  for  granted  the  ex¬ 
istence  of  pus  in  the  blood,  accounted  for  its  presence  b3^  the  supposition 
of  a  suppurative  phlebitis,  have  alread3^  been  disproved.  But  it  is  not 
unreasonable  to  suppose  that  the  fluid  portions  of  pus  ma3^  be  absorbed, 
and  ma3"  lead  to  septic  or  other  changes  in  the  blood.  The  evil  effects 
which  follow  the  use  of  sponges  in  hospital  practice,  and  the  readiness 
with  which  infection  may  be  thus  carried,  form  a  strong  argument  in 
favor  of  the  local  absorption  of  the  poisonous  material,  an  argument 
which  has  been  still  further  strengthened  b3^  the  successful  application 
of  the  antiseptic  principle  in  the  treatment  of  wounds.  The  softening 


618 


PYEMIA. 


and  breaking  down  of  clots  in  the  veins  is  so  frequenth"  connected  with 
this  condition  of  blood-poisoning,  that  it  is  difficult  to  determine  whether 
it  is  to  be  looked  upon  in  the  light  of  cause  or  of  effect.  That  clot-soft¬ 
ening  is  a  very  common  cause  of  metastatic  abscesses,  cannot  be  doubted; 
but  tliis  is  in  consequence  of  its  giving  rise  to  embolism,  rather  than  of 
its  exercising  any  septic  influence  upon  the  blood  itself.  As  suggested 
above,  it  is  not  improbable,  however,  that  the  condition  of  septicaemia 
may  give  rise  to  the  formation  of  abscesses  in  internal  organs,  apart 
from  any  influence  it  may  exert  upon  preformed  clots;  but  that  these 
abscesses  differ  from  those  resulting  from  the  impaction  of  embola,  both 
in  their  distribution  and  in  their  anatomical  characters,  being  never  sur¬ 
rounded  by  that  zone  of  hemorrhagic  injection  which  almost  invariably 
accompanies  the  latter. 

Post-Mortem  Appearances. — After  the  above  brief  sketch  of  the 
more  important  pathological  conditions  which  constitute  the  pj^mmic 
state,  the  appearances  to  be  found  after  death  in  an}"  fatal  case  may  be 
described. 

The  body  usually  changes  rapidly  after  death,  decomposition  setting 
in  at  an  early  period ;  the  skin  is  generally  of  a  dirty-yellow  tinge,  some¬ 
times  intensely  jaundiced,  with  numerous  spots  of  livid  mottling,  due  to 
the  occurrence  of  local  congestion.  Aii}^  external  wound  may  present  a 
gray  sloughy  or  dry  appearance;  and  dark  red  lines  maybe  seen  extend¬ 
ing  upwards,  indicating  the  course  of  the  veins  or  Ij^mphatics. 

The  Biood  will  often  be  found  to  be  of  a  dark  color,  fluid,  or  imper¬ 
fectly  coagulated,  although  sometimes  it  may  present  no  abnormal 
appearance  whatever.  Large  numbers  of  white  blood-corpuscles  may  be 
readily  seen  under  the  microscope,  sometimes  collected  into  masses,  or 
entangled  in  a  clot  so  as  to  give  it  a  milky  white  appearance. 

The  Heart  is  frequently  the  seat  of  small  extravasations,  which  may 
be  found  either  beneath  the  pericardial  or  endocardial  lining,  or  in  the 
muscular  substance  itself.  Sometimes,  though  not  veiy  often,  abscesses 
are  found  situated  either  in  the  wall  or  in  the  papillary  muscles ;  these 
are  usually  small  collections  of  puriform  matter,  rarely  much  larger  than 
a  pea,  and  often  surrounded  by  a  zone  of  congestion  or  hemorrhage. 
The  muscular  substance  is  flabby,  and  the  lining  membrane  of  both  the 
heart  and  aorta  is  more  or  less  deeply  stained  by  imbibition  of  the  col¬ 
oring  matter  of  the  blood.  Pericarditis  may  result  primarily  from  the 
formation  of  metastatic  abscesses  in  the  lieart,  but  is  usually  secondary 
to  the  inflammation  of  the  pleura,  which  is  often  very  intense. 

The  Lungs  are  much  congested,  especiall}'-  at  the  posterior  bases,  where 
the  tissue  is  friable  ;  sometimes  this  congestion  passes  into  true  pneu¬ 
monia,  which  almost  alwa3'S  exists  to  some  extent  at  least.  The  most 
important  condition  present  in  these  cases  is  the  existence  of  metastatic 
abscesses,  which  may  vary  much  in  number  and  size.  These  are  com¬ 
monly  found  scattered  over  the  surface,  and  are  almost  invariably  sur¬ 
rounded  by  a  zone  of  condensed  lung-tissue,  the  result  either  of  inflam¬ 
matory  action  or  of  hemorrhagic  injection  ;  and  are  still  further  sur¬ 
rounded  by  an  area  of  active  congestion.  The  position  of  these  abscesses 
is  usually  indicated  on  the  surface  by  a  slight  elevation ;  their  form  is  most 
commonly  wedge-shaped,  the  broader  part  or  base  being  directed  towards 
the  surface.  The  central  part  of  the  mass  consists  of  a  gray  slough, 
which  may  or  may  not  have  softened  down  into  a  grumous  semi-fluid 
matter.  The  area  of  hemorrhasje,  measurino;  from  one-eisrhth  to  half  an 
inch  in  breadth,  may  present  the  ordinaiy  characters  of  lung-apoplexy, 
closely  resembling  damson-cheese  on  section ;  or  it  may  appear  of  a 


POST-MORTEM  APPEARANCES. 


619 


tawny-yellow  color  from  partial  reabsorption  of  blood  pigment.  The 
size  of  these  deposits  varies  greatly,  from  less  than  that  of  a  pea  to  two 
or  more  inches  in  diameter.  They  are  most  commonly  found  on  the  pos¬ 
terior  surface  of  the  lower  lobe,  or  in  the  interlobular  fissure.  The  pleu¬ 
risy  which  accompanies,  and  probably  in  most  cases  results  from,  the 
formation  of  the  deposit  is  often  very  severe.  The  pleural  surface  is 
freel}^  covered  with  patches  of  inflammatory  lymph,  whilst  corresponding 
quantities  of  deeply  colored  turbid  fluid  are  usualh’’  collected  into  the 
pleural  sac.  Sometimes,  though  rarely,  small  collections  of  pus  are 
found  scattered  through  the  substance  of  the  organ  without  affecting  its 
pleural  surface,  or  giving  rise  to  an}^  of  the  wedge-shaped  masses  above 
described. 

The  Liver  frequeutl}^  presents  no  abnormal  appearances,  even  in  severe 
cases,  where  the  lungs  have  suffered  most  markedly ;  in  others,  again, 
it  is  the  seat  of  man}"  abscesses,  which  often  attain  a  very  large  size. 
The}"  have  much  the  same  character,  both  as  to  form  and  position,  as 
those  in  the  lungs,  and  are  usually  surrounded  by  a  zone  of  hemorrhage 
and  congestion.  When,  however,  they  occur  as  primary  abscesses 
without  any  deposits  in  the  lungs  preceding  them,  they  may  appear  as 
simple  collections  of  pus,  having  a  more  or  less  branched  arrangement. 
This  form  of  pysemic  deposit  does  not  appear  to  be  the  result  of  em¬ 
bolism,  but  to  be  referable  to  those  other  conditions  of  ichorrhmmia  or 
septicaemia  which  have  been  described  above.  It  must  be  remembered 
that  hepatic  abscess  may  result  from  intestinal  mischief,  either  typhoid 
or  dvsenteric ;  and  therefore  the  occurrence  of  this  condition  does  not 
necessarily  indicate  the  existence  of  general  pyaemia. 

The  Spleen  is  usually  large,  soft,  very  friable,  and  often  of  an  almost 
pulpy  consistence.  Infarcts  unconnected  with  the  pyaemic  state  are  fre¬ 
quently  met  with  in  this  organ  ;  metastatic  abscesses  are  not,  however, 
very  common. 

The  Kidneys  probably  stand  next  to  the  liver  in  the  order  of  fre¬ 
quency  with  which  they  are  affected.  They  are  very  frequently  con¬ 
gested,  and  sometimes  the  seat  of  destructive  nephritis;  when  abscesses 
appear,  they  present  the  same  varieties  as  those  found  in  other  parts. 

The  Intestines  rarely  suffer,  but  abscesses  may  be  found  in  the  sub¬ 
mucous  or  subserous  areolar  tissue.  Local  peritonitis  not  unfrequently 
follows  the  formation  of  hepatic  abscesses,  and  may  become  very  severe. 
Of  the  other  organs,  the  prostate  is  the  most  commonly  affected; 
abscesses  forming  in  the  venous  plexuses  which  surround  this  body. 
Metastatic  deposits  rarely  form  in  the  hrain^  although  embolism  of  the 
cerebral  arteries  is  not  uncommon  as  a  result  of  valvular  disease  of  the 
heart. 

One  or  more  Joints  are  usually  found  to  be  swollen  and  tender ;  and 
on  opening  them  a  large  quantity  of  pale  yellow  or  thick,  flaky,  and 
puriform  fluid  escapes.  There  are  congestion  of  the  synovial  fringes, 
and  softenino^  or  destruction  of  the  cartilaoe. 

The  general  character  of  the  anatomical  lesions  present  in  this  disease 
may  be  summed  up  as  follows:  a  general  tendency  to  local  congestion, 
inflammation,  or  extravasation  of  blood,  accompanied  by  the  formation 
of  slough  or  abscess,  due  in  the  majority  of  cases  to  thronfl30sis  or  em¬ 
bolism;  but  in  other  cases  to  changes  in  the  blood  itself,  which  almost 
always  presents  remarkable  fluidity,  and  a  tendency  to  rapid  decomposi¬ 
tion. 

Treatment. — The  Preventive  Treatment  of  pymmia  consists  in 
a  scrupulous  attention  to  those  hygienic  measures  which  have  been 


620 


PYEMIA. 


described  in  the  earlier  chapters  of  this  work ;  and,  above  all,  to  a  care¬ 
ful  avoidance  of  overcrowding.  It  is  impossible  to  speak  too  forcibly 
on  the  necessit}"  of  avoiding  this  evil  in  surgical  wards,  if  we  wish  to 
prevent  outbreaks  of  pyaemia.  Tlie  more  the  patients  are  isolated,  the 
less  will  be  the  liabilit}^  to  pj^aemia.  If  the  aggregation  of  patients 
favors  the  development  of  this  disease,  their  segregation  is  the  best 
preventive:  abundant  cubic  space  of  air,  free  ventilation,  and  scrupulous 
attention  to  cleanliness  will  do  more  to  prevent  the  development  and 
spread  of  pj^aemia  than  aii}^  other  precautions  that  may  be  adopted.  In 
fact,  none  are  of  an}^  avail  if  these  be  neglected.  Yet  it  is  impossible 
not  to  admit  that  the  constitution  of  the  patient  himself  ma}”  have  much 
to  do  with  the  production  of  the  disease ;  and  it  is  often  distressing  to 
the  Surgeon  to  feel  that,  wliatever  care  may  be  bestowed  upon  the  pa¬ 
tient  after  an  operation  or  accident,  in  these  respects,  the  evil  influences 
to  which  he  has  been  exposed  previouslj^  to  its  occurrence  may  have  so 
contaminated  his  blood,  that  pyaemia  becomes  almost  an  inevitable 
sequence  of  an}'  suppurative  inflammation  that  is  set  up. 

In  addition  to  ordinary  prophylactic  hygienic  measures,  there  are  a  few 
of  a  more  special  character.  Thus,  pus  should  always  be  freely  let  out, 
especially  if  it  be  sanious,  decomi)Osing,  or  offensive.  Quinine  or  iron 
may  be  given  before  an  operation,  or  as  soon  after  as  the  patient’s  con¬ 
dition  will  bear  it;  and  a  liberal  supply  of  good  nourishment  enjoined. 
Disinfectants,  especially  carbolic  acid  and  the  chlorides,  should  be  freely 
used.  Some  Surgeons  have  advocated  the  internal  administration  of 
agents  that  have  a  special  antiseptic  character,  as  the  hyposulphites  and 
sulpho-carbolates ;  but  their  use  does  not  seem  to  have  been  attended 
with  the  benefit  that  was  expected  from  them  on  theoretical  grounds. 

The  Curative  Treatment  of  pyaemia  is  most  unsatisfactory.  It  doubt¬ 
less  happens  that  patients  occasionally  recover  from  this  disease,  even 
after  the  formation  of  diffuse  abscesses ;  but  such  a  result  must  be  looked 
upon  as  a  happy  exception  to  its  commonly  fatal  termination.  The 
only  plan  of  treatment  that  holds  out  any  reasonable  hope  of  success, 
appears  to  me  to  be  the  stimulating  and  tonic  one,  consisting  of  brandy 
or  wine,  ammonia,  bark,  and  beef-tea;  in  fact,  tliat  plan  of  treatment 
which  is  usually  adopted  in  low  fevers  and  inflammations.  I  have  cer¬ 
tainly  seen  service  done  in  some  cases,  and  indeed  recovery  effected,  by 
the  administration  of  large  doses  of  quinine;  five  grains  being  given 
every  third  or  fourth  hour,  with  the  best  effect.  Beyond  this  I  do  not 
think  it  necessary  to  go.  Among  many  others  I  may  mention  a  very 
serious  case  of  pyaemia  following  amputation  of  the  arm,  and  accom¬ 
panied  not  only  by  all  the  symptoms  of  that  disease  in  a  very  marked 
degree,  but  by  pleuritic  effusion,  swelling  and  tenderness  over  one  hip, 
and  secondary  hemorrhage  from  the  stum^),  which  was  cured  under  the 
tonic  and  stimulating  plan  of  treatment.  The  quinine  very  decidedly 
checks  the  rigors ;  but  does  not  appear  to  influence  the  temperature  or 
the  sweats.  In  some  cases  I  have  administered  the  chlorate  of  potass 
largely  (5  ij  to  5  iv  in  the  day),  in  addition  to  the  quinine  and  wine, 
with  apparent  beneflt.  If  the  depression  be  very  great,  carbonate  of 
ammonia  in  five  to  ten  or  even  fifteen  grain  doses  may  be  given,  well 
diluted,  fronf  time  to  time ;  such  fluid  nourishment  as  the  patient  will 
take,  with  a  liberal  allowance  of  wine,  porter  or  brandy,  being  also  ad¬ 
ministered.  In  addition  to  this  medicinal  treatment,  hygienic  measures 
must  be  put  in  force.  The  patient  should  throughout  be  placed  in  an 
airy  and  well-ventilated  apartment,  and  cleanliness  carefully  attended  to. 


TUMORS. 


621 


In  the  case  of  a  superficial  vein  being  inflamed,  it  has  been  recom¬ 
mended  by  Bonnet,  Berard,  and  Laugier,  that  the  actual  cauteiy  should 
be  freely  applied  along  the  course  of  the  vessel ;  and  they  state  tliat  the 
best  results  have  followed  this  practice.  As  abscesses  form,  these  must 
be  freely  opened  ;  and  the  diflfuse  and  purulent  collections  forming  in 
the  areolar  tissue  must  be  evacuated;  the  cavities  being  well  syringed 
out  with  antiseptic  lotions. 

If  convalescence  take  place,  the  patient  will  slowly  recover.  The  rigors 
and  sweats  will  gradually  become  less  frequent ;  the  appetite  will  im¬ 
prove ;  the  countenance  will  lose  its  anxious  expression,  and  the  skin  its 
unhealthy  hue.  But  strength  returns  slowly.  The  disease  ma}'  assume 
a  relapsing  character.  Great  caution,  therefore,  is  necessaiy  before  a 
patient  can  be  pronounced  safe.  Even  after  recoveiy,  he  will  long  con¬ 
tinue  pale  and  wasted  ;  energy  is  lost ;  nutrition  impaired  ;  and,  at  a 
more  remote  period,  some  low  form  of  disease,  as  phthisis  or  albuminuria, 
may  prove  fatal. 


CHAPTER  XXXIY. 

TUMORS.' 

The  frequency  with  which  Tumors  fall  under  the  observation  of  the 
Surgeon,  the  great  variet}^  in  their  characters,  and  their  important  rela¬ 
tions,  local  as  well  as  constitutional,  render  their  consideration  one  of 
great  moment.  According  to  Hunter,  a  tumor  is  “a  circumscribed  sub¬ 
stance  produced  b}’  disease,  and  different  in  its  nature  and  consistence 
from  the  surrounding  parts.”  This  definition,  though  not  perhaps  accu¬ 
rate!}' correct  in  some  forms  of  tumor,  which  do  not  differ  in  their  nature 
from  neighboring  parts,  is  3'et  clinically  convenient.  By  a  tumor  may 
also  be  said  to  be  meant  a  more  or  less  circumscribed  mass,  growing  in 
some  tissue  or  organ  of  the  body,  and  dependent  on  a  morbid  excess  of, 
or  deviation  from,  the  nutrition  of  the  part.  These  growths  may  there¬ 
fore  be  considered  under  the  two  heads  of  local  ly'pertrophies,  or  out¬ 
growths  of  the  normal  structure  of  the  part ;  and  of  new  formations, 
presenting  structural  characters  which  differ  more  or  less  widel}'  from 
those  of  the  parts  around.  The  tumor  thus  formed  increases  in  size  by 
an  inherent  force  of  its  own,  irrespectively  of  the  growth  of  the  rest  of 
the  S3’stem,  but  still  obe3’s  the  same  laws  of  growth  which  govern  the  body 
generall}^  In  order  to  constitute  a  tumor,  it  is  necessary  that  the  nor¬ 
mal  form  of  the  part  be  widely  departed  from  ;  a  mere  increase  in  its 
size,  so  long  as  it  preserves  its  usual  shape,  being  scarcely  considered  in 
this  light.  Thus,  if  the  tibia  be  uuiforml}'  enlarged  to  double  its  natural 
size,  the  enlargement  is  a  hypertroph}’ ;  but  if  a  comparative!}’’  small 
rounded  mass  of  bone  project  directl}"  forwards  from  its  tuberosit}',  it 
is  said  to  be  a  tumor  and  not  a  mere  h3’pertroph3'. 

'  The  most  exhaustive  treatise  on  this  subject  is  Virchow’s  great  work,  Die 
Krankhaften  Gescliwulste  (the  Pathology  of  Tumors')  ;  whilst  in  his  Cellular  Pa¬ 
thology  will  be  found  an  exposition  of  his  views  of  the  development  of  new  forma¬ 
tions,  The  reader  will  find  in  Paget’s  classical  Lectures  on  Surgical  Pathology  the 
best  account  in  the  English  language  of  the  clininal  characters  of  these  growths. 


622 


TUMORS. 


Classification  of  Tumors. — A  classification  of  tumors  may  be 
founded  either  upon  their  anatomical  structure,  or  upon  their  vital  and 
clinical  characters  ;  and,  although  these  two  symptoms  may  occasional!}* 
lead  to  a  somewhat  similar  grouping  of  individual  growths,  yet  our 
knowledge  is  at  present  too  imperfect  to  enable  us  to  point  out  in  every 
case  the  connection  between  clinical  history  and  histological  structure. 
Surgeons  have  long  divided  tumors  into  two  great  classes — the  Non-ma- 
lignant  and  the  3Ialignant.  This  division,  however,  though  practically 
convenient,  is  not  scientifically  exact.  Although  some  tumors,  as  the 
cancers,  are  always  and  essentially  malignant,  and  others  as  uniformly 
benign,  as  lipomata  and  some  cysts,  yet  many  others  that  are  usually 
innocent  may,  under  certain  conditions  at  present  unknown,  take  on  a 
truly  malignant  action :  this  has  led  to  the  establishment  of  an  interme¬ 
diate  group  that  may  be  termed  the  Semi- Malignant. 

The  Non-3Ialignant,  Innocent^  or  Benign  Tumors  are  strictly  local  in 
their  development,  and  are  rarely  connected  with  any  constitutional  or 
hereditary  peculiarity.  They  resemble  more  or  less  completely  the  nor¬ 
mal  textures  of  a  part,  and  hence  are  very  commonly,  though  not  per¬ 
haps  with  strict  propriety,  termed  homomorphous.  They  usually,  though 
not  invariably,  grow*  slowly,  are  more  or  less  distinctly  circumscribed, 
being  often  inclosed  in  a  cyst,  and  have  no  tendency  to  involve  neighbor¬ 
ing  structures  in  their  own  growTh;  any  change  that  they  induce  in  con¬ 
tiguous  parts  not  consisting  in  the  degeneration  or  conversion  of  these 
into  their  owm  structures,  but  simply  in  displacement  or  atroj^hy  by  their 
size  and  pressure.  They  are  sometimes  single,  but  not  unfrequently 
multiple,  developing  either  simultaneously  or  successively;  but,  if  in  the 
latter  mode,  without  any  connection  w*ith  preceding  growths.  If  removed 
by  operation,  they  do  not  return;  but  if  left  to  the  natural  processes  of 
nature,  they  may  slowdy  attain  a  great  size,  remain  stationary,  and,  at 
last,  atrophy,  decay,  or  necrose. 

The  essentially  Malignant  Tumors  differ  widely  from  those  last  de¬ 
scribed.  They  cannot  be  considered  as  strictly  local  diseases,  as  in  many 
cases  they  result  primarily  from  a  constitutional  or  hereditary  vice,  or, 
if  local  in  the  first  instance,  have  a  tendency  rapidly  to  affect  the  con¬ 
stitution,  and  to  reproduce  themselves  in  distant  parts  of  the  body. 
They  are  usually  characterized  by  extreme  vegetative  luxuriance,  and 
by  exuberant  vitality.  They  represent  an  extreme  departure  from  the 
ordinary  nutrition  of  the  part,  and  when  once  found  in  any  organ  or  tis¬ 
sue,  they  develop  by  an  inherent  force  of  their  ow*n,  irrespectively  of 
neighboring  parts,  producing  masses  which  differ  entirely  in  structure 
and  appearance  from  anything  observed  in  the  normal  condition  of  the 
body,  and  hence  are  not  unfrequently  called  heteromorphous.  This  term, 
however,  cannot  be  considered  strictly  accurate;  inasmuch  as  the  micro¬ 
scopic  elements  of  w’hich  the  masses  are  composed  have  their  several 
analogues  in  the  normal  structures  of  the  body.  But  though  the  indi¬ 
vidual  constituents  of  the  tumor  may  be  normal,  their  aggregation  and 
mode  of  arrangement  are  totally  abnormal,  and  differ  from  everytliing  met 
with  in  a  healthy  state  of  the  tissues.  The  mass,  which  may  either  be 
infiltrated  in  the  tissues,  or  localized  by  being  confined  to  a  cyst,  increases 
quickly  in  size ;  not  uncommonly,  indeed,  the  rapidity  of  the  growth  may 
be  taken  as  a  measure  of  the  malignancy  of  the  tumor.  As  it  increases 
in  size  it  tends  to  implicate  the  neighboring  structures  in  its  own  growth, 
and  to  affect  distant  organs  through  the  medium  of  the  lymphatics  or 
the  blood  ;  if  removed  by  operation  it  has  a  great  tendency,  under  certain 
conditions,  local  and  constitutional,  to  return  in  its  original  site  or  else- 


CHARACTERS  OF  MALIGNANT  TUMORS. 


623 


■where,  though  it  does  not  necessarily  do  so.  If  left  to  its  own  develop¬ 
ment,  a  malignant  tumor  will  inevitably  soften,  necrose,  and  ulcerate, 
often  with  much  pain,  profuse  hemorrhage,  and  the  induction  of  a  pecu¬ 
liar  state  of  constitutional  cachexy,  which  speedily  and  necessarily  termi¬ 
nates  in  death. 

The  followdug  may  be  looked  upon  as  the  principal  signs  of  malig¬ 
nancy  in  those  tumors — as  cancers,  which  are  anatomically  as  well  as 
pathologicall}^  malignant — in  which,  in  fact,  the  structure  taken  as  a 
whole  differs  from  anything  that  normally  exists  in  the  body,  and  in 
which  the  progress  of  the  disease  has  an  invariable  tendency  to  proceed 
from  a  primary  local  to  a  secondary  constitutional  condition. 

1.  The  tumor,  whether  arising  spontaneously  or  as  the  result  of  ex¬ 
ternal  violence,  whether  occurring  in  an  individual  in  whom  there  has 
previously  existed  an  hereditary  tendency  to  similar  or  to  allied  disease, 
or  in  one  whose  progenitors  have  never  evinced  any  tendency  to  similar 
affections,  is  invariably  at  first  small,  and  is  usually  circumscribed  with 
a  distinct  outline. 

2.  There  is  a  constant  tendency  to  the  extension  of  the  disease  by 
local  infiltration  into  and  the  absorption  of  neighboring  structures  ;  not 
only  by  their  mere  absorption  by  the  pressure  of  an  increasing  growth, 
but  by  their  actual  incorporation  into  its  very  substance,  and  the  deposit 
of  the  morbid  mass  in  their  place. 

3.  This  process  continues  uninterruptedly ;  in  man}''  cases  veiy  slowly, 
as  in  scirrhus  of  the  breast;  in  others,  in  special  forms  of  disease,  and 
in  certain  situations,  as  in  encephaloid  of  the  bones,  of  the  eye,  or  of 
the  testes,  very  rapidly. 

4.  The  rapidity  of  the  growth  of  the  tumor,  and  of  the  absorption 
and  incorporation  of  the  neighboring  structures,  is  usually  in  the  mea¬ 
sure  of  and  in  proportion  to  the  malignancy  of  the  affection. 

5.  The  course  of  the  tumor  is  always  a  definite  one  until  it  attains 
the  maximum  of  its  development.  When  once  this  culminating  point 
is  reached  it  undergoes  a  process  of  softening,  of  disintegration,  and  of 
sloughing,  with  considerable  discharge,  usually  of  an  offensive  character, 
and  not  unfrequently  with  abundant  hemorrhage. 

6.  At  a  certain,  period  of  the  growth — early  in  some  cases,  not  until 
many  months  have  elapsed  in  others — the  lymphatics  and  the  absorbent 
glands  immediately  above  the  primary  disease,  those  intervening  between 
it  and  the  central  portion  of  the  system,  become  enlarged  and  hardened, 
in  consequence  of  the  deposit  within  them  of  morbid  material  identical 
in  character  with  that  which  constitutes  the  primary  or  original  disease. 
This  secondaiy  implication  of  the  lymphatic  glands  is  undoubtedly  due 
to  direct  absorption.  It  ma}’’  occur  before  the  skin  is  involved  ;  but 
invariably  manifests  itself  w'hen  once  the  integumental  structures  are 
implicated  in  and  infiltrated  by  the  malignant  disease.  The  disease  has 
a  tendency  to  run  the  same  course  in  the  glands  that  are  thus  secon¬ 
darily  affected  as  it  does  in  its  primary  seat. 

7.  At  a  later  period  than  this  the  internal  organs,  more  especially  the 
lungs  and  liver,  become  the  seat  of  secondary  deposits  of  a  similar 
nature  essentially,  though  differing  possibly  in  some  minor  characters, 
to  those  which  were  primarily  developed  in  the  original  seat  of  the  local 
affection.  These  secondary  visceral  deposits  occasionally  become  the 
foci  of  new  developments  of  the  disease,  which  assume  a  more  fatal 
character  than  the  primary  affection  to  which  they  owe  their  origin. 

8.  After  the  contamination  of  the  lymphatic  glands,  the  constitution 
of  the  patient  exhibits  evidences  of  serious  modifications  in  nutrition 


624 


TUMOES. 


and  sangnification.  The  body  wastes,  the  skin  becomes  sallow,  the 
digestive  powers  become  impaired,  and  ansemia  supervenes. 

9.  Death  may  occur  in  various  ways :  from  the  exhaustive  effects  of 
the  discharges,  and  hemorrhages  from  the  local  and  primary  disease ; 
from  special  visceral  disturbance  induced  by  the  secondary  deposits,  or 
from  malnutrition  and  consequent  cachexy. 

The  malignant  tumors  are  usually  of  a  cancerous  nature,  but  “ 
nanV^  and  “  canceroua'^''  are  not  synonymous  terms.  Every  malignant 
tumor  is  not  a  cancer,  though  eveiy  cancer  is  a  malignant  growth.  Some 
tumors  occasionally  present  the  clinical  characters  of  malignancy,  though 
structurally  they  are  intimatel}^  connected  with  others  which  are  usually 
looked  upon  as  essentiall}'  non-malignant ;  and  we  are  thus  obliged  to 
consider,  that  these  terms  are  merely  relative,  and  that  these  two  great 
classes  pass  into  one  another  by  insensible  gradations.  It  will  be  sub¬ 
sequently  seen  that  the  fibroid,  fibro-plastic,  and  cartilaginous  tumors 
stand  in  this  intermediate  position  between  the  more  typical  examples  of 
these  two  great  groups.  Those  benign  tumors  which  have  a  tendency  to 
recur  after  removal,  and  thus  to  run  as  it  were  a  locally  malignant  course, 
are  usually  very  rapid  in  their  growth  and  development.  Indeed,  great 
rapidity  of  growth  may  usually  be  looked  upon  as  either  an  evidence  of 
malignancy  of  structure  or  of  liability  to  speedy  recurrence  after  extir¬ 
pation.  These  rapidly  growing  and  recurrent  tumors,  simple  in  struc¬ 
ture  but  malignant  in  course,  are  chiefly  met  with  in  the  bones  and 
testicle  as  enchondromata,  in  the  breast  as  adenomata  and  fibroid  tumors. 
In  some  cases,  after  repeated  removals,  the  tendency  to  recurrence  ap¬ 
pears  to  wear  out,  and  the  patient  eventually  overcomes  the  disease. 
But  in  other  instances  this  fortunate  result  does  not  occur.  Where 
tumors  of  any  kind  recur  after  removal,  it  will  be  found  that  the  secon¬ 
dary  differs  in  maii}^  important  respects  from  the  primaiy  growth.  Thus 
it  will  be  found  to  be  softer,  semi-diffluent,  often  more  vascular  and  more 
diffused.  In  microscopical  structure  it  will  be  found  to  present  evidences 
of  more  activity  of  growth,  departing  more  widel}^  from  the  normal  type 
and  approximating  more  closely  to  malignancy.  Paget  has  very  fully 
described  varieties  of  the  fibro-plastic  as  well  as  of  the  fibrous  and  car¬ 
tilaginous  tumor,  which,  though  preserving  throughout  an  uniform 
character,  microscopical  and  otherwise,  which  is  not  considered  malig¬ 
nant,  have  nevertheless  destroyed  the  patient  by  repeated  recurrence 
after  removal,  and  by  ultimate  ulceration,  sloughing,  and  contamination 
of  neighboring  tissues,  or  even  of  distant  organs  through  the  medium  of 
the  circulation.  He  makes  the  important  observation  that,  in  different 
persons  and  under  different  conditions,  the  same  disease  ma^q^ursue  very 
opposite  courses,  appearing  in  some  to  be  of  an  innocent,  in  others  of  a 
malignant  type  ;  and  he  makes  the  very  interesting  practical  remark, 
which  agrees  entirely  with  the  result  of  my  own  observation,  that  the 
children  of  cancerous  parents  may  be  the  subject  of  tumors  apparently 
innocent  in  structure,  but  closely  resembling  malignant  growths  in  the 
rapidity  of  their  progress,  their  liability  to  ulcerate  and  to  bleed,  and 
their  great  disposition  to  return  after  removal. 

The  term  Semi-malignant  ma}"  be  employed  to  include  those  growths 
which  occupy  the  doubtful  position  indicated  above:  it  must,  however, 
be  distinctly  understood  that  these  terms  cannot  be  employed  in  any 
very  definite  sense. 

Innocent  and  malignant  tumors  are  occasionally  met  with  in  the  same 
person,  four  or  five  different  kinds  of  growth  even  occurring  in  one  indi¬ 
vidual.  I  have  seen  in  one  patient  a  scirrhous  breast,  an  enchondroma- 


CLASSIFICATION  OF  TUMORS. 


625 


tons  tumor  of  the  leg,  and  an  atheromatous  cyst  on  the  back,  with  scro¬ 
fulous  glands  in  the  neck.  Xew  formations  of  different  tj’pes  may  even 
be  found  in  the  same  mass ;  thus,  encephaloid  and  enchondroma  are  not 
unfrequentl}"  met  with  together  in  the  testis.  This,  however,  must  not 
be  taken  as  any  evidence  of  the  possibilit}^  of  the  conversion  of  one  into 
the  other,  but  rather  as  the  result  of  a  departure  in  different  directions 
from  the  normal  nutrition.  There  is  indeed  no  proof  that  a  non-malig- 
nant  can  be  converted  in  any  circumstances  into  a  malignant  tumor  of 
a  different  type  ;  a  fibrous  growth  may  degenerate  and  assume  all  the 
character  of  malignanc}”,  at  last  destroying  the  patient,  but  there  is  no 
evidence  that  it  can  ever  be  changed  into  a  cancerous  mass.  A  malig¬ 
nant  tumor  may,  however,  appear  on  the  site  of  a  non-malignant  growth 
that  has  been  removed :  thus  I  have  seen  a  scirrhous  nodule  deposited 
in  the  cicatrix  left  after  the  removal  of  a  C3’stic  sarcoma  of  the  breast. 

Besides  these  various  forms  of  tumors,  others  are  met  with,  of  a  con¬ 
stitutional  and  specific  character,  such  as  those  that  occur  in  connection 
with  scrofula  and  S3"philis. 

The  following  classification  will  be  found  to  be  clinicall3"  useful, 
although  it  can  hardl3"  be  considered  as  anatomicall}’  correct : — 

I.  Xon-Malignant  and  Semi-Malmnant  Tumors. 

1.  C3’'stic  Tumors  of  all  kinds. 

2.  Tumors  dependent  on  the  Simple  Increase  of  Size  of  already 
existing  Structures  in  the  tissues  or  organs  in  which  the3' occur;  as, 
for  instance,  fatt3"  tumors  in  adipose  tissue,  exostosis  in  connection 
with  bone,  adenoid  tumors  in  the  breast,  etc. 

3.  Tumors  dependent  on  the  Xew  Growth  of  already  existing 
Structures  in  situations  where  the3"  are  not  normall3^  found ;  as,  for 
instance,  a  cartilaginous  tumor  in  the  midst  of  areolar  tissue,  or  an 
osseous  tumor  in  a  gland.  It  is  in  this  class  that  the  semi-malignant 
growths  are  found. 

II.  Malignant  Tumors. 

1.  Encephaloid ;  representing  the  more  acute  form. 

2.  Scirrhus  ;  representing  the  more  chronic  form. 

3.  Epithelial  Cancer. 

The  other  varieties  of  cancer  usuall3^  enumerated  are.  Melanotic  or 
Black  Cancer,  and  Colloid  or  Glue  Cancer ;  of  these  the  former  seems 
to  be  merel3^  a  variety  of  encephaloid,  and  the  latter  is  probably  not  a 
true  cancer. 

A  classification  founded  upon  an  anatomical  basis  not  onl3^  enables  the 
observer  to  comprehend  the  precise  relation  which  an3^  particular  growth 
under  observation  bears  to  others  that  resemble  it ;  but  it  leads  him  to 
trace  the  origin  of  the  new’  formation  from  the  pre-existing  structures  of 
the  part  in  w’hich  it  occurs,  thus  forming  the  first  step  towards  a  know¬ 
ledge  of  the  aetiology  of  the  disease.  Tumors  are  said  to  be  heterolo¬ 
gous  or  homologous,  according  as  the3"  present  a  greater  or  less  devia¬ 
tion  from  the  normal  condition  of  the  tissues  from  which  the3''  spring. 
These  terms  are  essentiall3m’elative  ;  and  it  is  only  to  individuals  at  the 
extreme  ends  of  the  series  that  either  term  can  be  definitely  applied. 
The  more  heterologous  the  growth,  that  is,  the  greater  the  departure 
from  the  normal  nutrition  of  the  part  in  w’hich  it  occurs,  the  more  malig¬ 
nant,  as  a  rule,  will  be  its  action  upon  the  S3’stem  generally  ;  whilst  the 
reverse,  with  similar  exceptions,  is  true  of  homologous  formations.  At 
the  same  time  it  must  be  borne  in  mind,  that  Virchow’s  law  holds  good 
even  in  the  most  heterologous  departures  from  the  standard  of  health ; 
this  law'  states,  that  “  the  same  t3^pes  of  anatomical  structures  exist  in 

VOL.  I _ 40 


626 


TUMOES. 


new  formations  as  are  found  in  the  body  generally,”  and  thereby  denies 
the  possibility  of  the  occurrence  of  a  true  heteroplasia,  and  the  existence 
of  specific  elements  in  new  formations. 

The  following  classification  may  be  adopted  as  possessing  the  same 
clinical  convenience  as  that  given  above,  at  the  same  time  that  it  presents 
the  additional  advantage  of  anatomical  uniformity. 

I.  Cystic  Tumors  generally. 

II.  Tumors  produced  by  Local  Hyperplasia  of  Complex  Structures, 
as,  for  instance,  papillary  and  glandular  formations. 

III.  Tumors  possessing  a  Structure  belonging  to  the  Connective  Tis¬ 
sue  type  ;  the  fibroid,  the  cartilaginous,  and  the  osseous. 

lY.  Tumors  possessing  a  Structure  belonging  to  the  Epithelial  type; 
the  cancers,  encephaloid,  scirrhous,  and  epithelial. 

Y.  Tumors  derived  from  the  Lymphatic  Tissue  type ;  lymphoid  and 
tubercle ;  lymphadenoma. 

Before  proceeding  to  consider  the  individual  growths,  which  are  thus 
grouped  together,  it  will  be  desirable  to  describe  briefl}^  the  essential 
features  presented  by  the  structures,  upon  the  type  of  which  the  third 
and  fourth  classes  are  founded. 

The  elements  of  the  connective  or  areolar  tissue  exist  throughout  the 
body,  presenting  however  many  varieties  of  form  adapted  to  the  special 
functions  of  each  particular  part  in  which  it  appears.  It  consists  essen¬ 
tially  of  an  intercellular  substance,  h3^aline  or  fibrillated,  in  wLich  are 
imbedded  cells  having  an  oval,  caudate,  fusiform  or  branched  form,  and 
usually  presenting  a  distinct  neucleolus.  The  connective  tissue  cell  is 
now  generally  looked  upon  as  a  modification  and  derivative  of  the  l^^mph 
or  white  blood-corpuscles,  and  probably  gives  origin  in  some  circum¬ 
stances  to  the  inflammatory  l^miph  pus-corpuscle.  It  usuallj^  presents 
itself  as  an  oval  or  fusiform  cell  measuring  about 

in  diameter,  with  a  nucleus  and  nucleolus,  which  are  rendered  distinct 
b^’  the  addition  of  water  or  acetic  acid.  This  corpuscle  is  looked  upon 
by  the  cellular  pathologists  as  the  starting  point  from  which  are  derived 
the  various  cell-structures,  which  constitute  a  large  proportion  of  the 
products  of  abnormal  nutrition. 

The  following  tissues  may  be  considered  as  belonging  to  this  type,  the 
pathological  deviations  from  which  must  be  viewed  in  the  same  light : — 
the  connective  or  areolar,  the  white  fibrous,  and  the  3'ellow'  elastic  tissues 
in  all  parts  of  the  bod}^,  whether  entering  into  the  formation  of  organs, 
or  existing  as  separate  structures.  The  cartilaginous  and  osseous  tissues 
represent  two  important  modifications,  but  exhibit  occasionall}’’  a  ten¬ 
dency  to  return  to  the  primary  form  as  described  above. 

The  essential  character  of  the  epithelial  t^q^e  is,  that  it  presents  a 
simple  cell-structure  without  any  intercellular  substance.  The  cells 
are  in  all  probabilit}^  derived  from  the  same  source  as  the  connective 
tissue  corpuscles.  As  a  normal  element,  epithelium  can  only  exist  on 
free  surfaces,  and  it  is  to  be  found  on  all  the  membranes  lining  the  cavi¬ 
ties  of  the  bod^'.  ^Yhen  developed  in  any  other  position  than  this,  it 
constitutes  the  greatest  departure  from  health^’  structure  which  may  be 
met  with.  The  cells  of  epithelium  present  a  very  great  variety  in  their 
form  and  size,  and,  though  usually  possessing  but  one  nucleus,  may  some¬ 
times  contain  several  nuclei,  as  in  the  transitional  epithelium  from  the 
bladder. 

The  characters  presented  bj^  the  several  groups  of  tumors  will  now 
be  considered. 


CYSTIC  TUMOES, 


627 


I.— CYSTIC  TUMORS. 

Cystic  Tumors  may  be  classified  according  to  their  contents,  or  accord¬ 
ing  to  their  anatomical  characters  and  mode  of  development.  The  fol¬ 
lowing  is  an  example  of  the  former  method. 

1.  Dermoid  Cysts,  presenting  three  varieties —  v 

a.  Those  containing  Epidermis. 

b.  Those  containing  True  Skin,  Hair,  and  Glands. 

c.  Those  containing  Cartilage,  Bone,  and  Teeth. 

2.  Serous  Cysts,  arising  in  four  different  ways — 

a.  By  Dilatation  of  Sacs,  Cavities  or  Canals,  including  Blood¬ 

vessels. 

b.  By  Accumulation  of  Fluid  in  the  Meshes  of  Areolar  Tissue. 

c.  By  Changes  in  Hemorrhagic  Effusions. 

d.  By  Changes  in  the  Products  of  Inflammation. 

3.  Colloid  Cysts,  resulting  from — 

a.  Colloid  Degeneration  of  Pre-existing  Cells. 

b.  Colloid  Deg^eration  of  Newly  formed  Cells. 

The  second  method  will,  however,  be  adopted  here  as  being  the  more 
simple  and  more  clinically  useful.  Cystic  tumors  are  divided  into  two 
great  classes: — 

1.  Those  that  are  dependent  upon  the  gradual  Accumulation  of  a  Se¬ 
cretion  in  a  naturally  existing  Duct  or  Cyst,  with  dilatation  and  hyper 
trophy  of  its  w’alls. 

2.  Those  that  result  from  the  New  Formation  of  a  closed  Cyst  in  the 
areolar  tissue  of  the  part,  and  the  distension  of  it  by  the  secretion  from 
its  lining  membrane. 

1.  Encysted  Tumors,  arising  from  Simjyle  Distension  and  Gradual 
Hypertrophy  of  the  Walls  of  a  Duct  or  Cyst,  are  met  with  in  three 
forms:  (a)  Encysted  tumors  of  the  skin  and  subjacent  areolar  tissue 
occurring  in  various  parts  of  the  bod3’’,  and  dependent  on  the  closure  of 
the  excretoiy  ducts  of  the  sebaceous  glands:  (6)  Tumors  formed  by  the 
accumulations  of  secretions  in,  and  the  closure  and  dilatation  of,  the 
ducts  of  other  secreting  glands  and  organs,  as  in  the  sublingual  or  the 
mammary  gland:  (c)  Those  formed  by  the  retention  and  modification 
of  the  secretions  in  cysts  without  excretoiy  ducts,  as  in  the  bursae. 

(a)  Encysted  Tumors,  produced  by  the  Obstruction  of  the  Excretory 
Ducts  of  the  Sebaceous  Glands,  include  the  various  forms  of  Athej'onia- 
tous  Tumors  that  are  met  with  on  the  surface  of  the  bod}".  These  are 
usually  situated  upon  the  scalp,  face,  neck  or  back;  sometimes,  however, 
they  occur  elsewhere — thus  I  have  removed  a  very  large  one  from  the 
forepart  of  a  girPs  arm,  and  others  from  the  labia  and  groin.  The  size 
of  these  tumors  varies  from  that  of  a  pin’s  head  to  an  orange;  the 
smallest  occur  on  the  eyelids,  the  largest  on  the  shoulders  and  scalp. 
They  are  often  very  numerous,  especially  about  the  head,  where  as 
many  as  thirty  or  forty  may  be  met  with  at  the  same  time;  and  most 
frequently  they  form  in  women  about  the  middle  period  of  life:  they  are 
smooth,  round,  or  oval,  movable  under  the  integument,  either  semi- 
fluctuating  or  elastic,  though  sometimes  solid  to  the  touch.  In  some 
23arts  where  the  sebaceous  follicles  are  large,  as  on  the  back,  a  small 
black  point  can  often  be  detected  on  the  surface  of  the  tumor,  through 
which  an  aperture  may  be  found  leading  into  its  interior,  and  allowing 
the  expulsion  of  its  contents.  A  sebaceous  tumor  is  composed  of  a  cyst 
which  varies  greatly  in  thickness,  being  sometimes  thin,  filamentous, 
and  soft ;  in  other  cases  so  thick,  hard,  laminated,  and  elastic,  that  it  is 


/ 


628 


T  u  :\t  0  R  s . 


Fig.  213. 


almost  impossible  not  to  believe  it  to  be  a  new  formation.  These  cysts 
attain  their  greatest  tlensit}^  on  the  scalp,  and  are  here  often  very  firm, 
elastic,  and  resisting,  even  though  of  but  small  size.  In  structure  they 
consist  of  cellulo-fibrous  tissue,  with  an  epithelial  lining,  and  generally 

appear  to  be  dilated  and  hypertrophied  se¬ 
baceous  follicles ;  though  not  imjDrobably, 
as  Paget  supposes,  they  may  at  times  be 
new  formations.  The}^  are  usually  attached 
b}^  loose  areolar  tissue  to  the  subjacent 
parts ;  but  if  thin,  they  are  often  rather 
closely  incorporated  with  the  superimposed 
skin.  If  inflammation  be  set  up  around 
them,  they  become  more  solidl}’-  fixed  ;  but, 
if  the  inflammation  go  on  to  suppuration, 
they  may  loosen  and  so  be  enucleated.  The 
contents  of  these  cysts  are  very  various, 
most  usuall}^  consisting  of  a  soft,  creann', 
pultaceous,  or  chees3^-looking  mass,  of  yel¬ 
lowish-white  color,  which  has  sometimes  in 
old  cysts  become  dry  and  laminated,  look¬ 
ing  not  unlike  parmesan.  In  some  cysts  of 


Contents  of  Sebaceous  Tumor  ;  Choles- 
teriue,  Fatty  and  Granular  Matters. 


old  standing  and  large 

o  o 

being- 


size,  the 


contents  ina^’^  be  semi-fluid,  the  more 


liquid  parts  being  of  a  brown,  green,  or  blackish  tint.  These  various 
contents  are  essentially  composed  of  sebaceous  secretion,  mixed  in 
various  proportions  with  epithelial  scales,  fat-granules,  cholesterine, 
granular  matter,  and  rudimentary  hairs  (Fig.  213). 

Progress. — The  growth  of  these  tumors  is  often  veiy  slow ;  but  not 
unfrequentl}^  after  remaining  stationaiw  for  j’ears,  they  take  on  a  rather 
rapid  increase.  The  tumor  itself,  though  painless,  may  give  rise  to 
uneasy  sensations,  by  compressing  nerves  in  its  vicinity ;  it  usually 
continues  to  grow  slowly,  until  the  patient,  being  annoyed  by  its 
presence,  has  it  removed  by  operation.  If  left  untouched,  it  occasion¬ 
ally,  though  rarely,  happens  that  the  sebaceous  matter  exuding  through 
an  aperture  on  its  surface  forms  a  kind  of  scab  or  crust,  which  by  a 
process  of  subdeposition  becomes  conical ;  and,  being  gradually  pushed 
up  from  below,  at  the  same  time  that  it  assumes  bj^  exposure  a  dark 
brown  color,  forms  an  excrescence  that  looks  like  a  horn,  and  is  usually 
considered  to  be  of  that  character.  These  “horns”  have  been  met  with 
on  the  head,  on  the  buttock,  and  in  other  situations.  The  accompanying 
drawing  (Fig.  214)  is  taken  from  a  child  four  years  old,  brought  to  me 
to  have  its  horn  removed ;  a  woman  also  once  applied  to  me  with  one 
about  an  inch  and  a  half  long,  growing  from  the  upper  lip. 

In  other  cases,  these  tumors  inflame  and  suppurate;  the  skin  covering 
them  becomes  adherent  and  reddened,  ulceration  takes  place,  and,  if  the 
C3^st  be  small  and  dense,  it  may  be  thrown  off  by  the  suppurative  action 
in  the  surrounding  tissues.  If  it  be  larger,  ulceration  or  the  integu¬ 
ments  covering  it  takes  place,  and  the  sebaceous  matter  is  exposed;  this 
may  then  putrefy,  become  offensive,  and  break  away  in  unhealthy  sup¬ 
puration.  In  other  cases,  peculiar  changes  take  place  in  this  tissue: 
large  granulations  are  thrown  out  in  it,  and  the  atheromatous  mass 
appears  to  vascularise,  becoming  irregular  and  nodulated,  rising  up  in 
tuberous  growths  with  everted  edges,  exuding  a  fetid,  foul  discharge, 
becoming  adherent  to  subjacent  parts,  and  assuming  a  semi-malignant 
appearance,  forming  at  last  a  sore  as  large  as  a  saucer  (Fig.  215),  and 
then  becoming  closely  allied  to  epithelioma  or  to  rodent  ulcer.  Seba- 


TREATMENT  OF  SEBACEOUS  CYSTIC  TUMORS. 


629 


ceous  cysts  which  have  imclergone  this  change  ma}^,  however,  readily 
be  distinguished  from  malignant  growths  by  a  microscopical  examina¬ 
tion  of  their  exudations  or  debris;  these  consisting  of  pus  and  healthy 
epithelium,  mixed  up  with  fatty  matters  more  or  less  disintegrated. 


Fig.  214. 


Horn  on  Nose  of  a  Child. 


Fig.  215. 


Ulcerated  Encysted  Tumor  of  Scalp. 


Diagnosis. — The  only  diseases  with  which  these  tumors  can  be  con¬ 
founded  are  abscesses  and  fatty  growths.  From  an  abscess  an  encysted 
sebaceous  tumor  ina}^  be  distinguished  by  its  history,  slow  growth,  situa¬ 
tion,  elasticity,  and  mobility,  and  the  existence  of  the  dilated  orifice  of 
the  sebaceous  duct,  through  which  some  of  the  contents  can  be  squeezed, 
the  microscopical  examination  of  which  will  serve  to  confirm  the  diag¬ 
nosis.  From  fatty  tumors  these  growths  may  be  diagnosed  b}"  their 
firmer  and  more  regular  feel:  and  in  case  of  doubt  by  the  evacuation  and 
examination  of  their  contents. 

The  Treatment  of  a  tumor  of  this  kind  simply  consists  in  its  removal, 
after  which  it  is  never  reproduced.  So  long  as  these  tumors  are  small, 
and  do  not  give  rise  to  deformity  or  inconvenience,  they  may  be  left 
without  surgical  interference.  But  when  large,  and  more  particularly 
when  they  have  become  inflamed,  they  should  be  removed.  The  method 
of  operation  will  vary  according  to  their  situation  and  the  thickness  of 
their  walls.  When  situated  on  the  scalp,  where  the  cj^st  is  dense  and 
tough,  the  tumor  may  very  readily  be  removed  b}'  transfixing  the  upper 
part  of  it  and  the  skin  covering  it  with  a  scalpel,  squeezing  out  the  athe¬ 
roma,  and  then  seizing  the  edge  or  bottom  of  the  cyst  with  forceps  and 
pulling  it  out.  In  this  little  operation  there  are  two  points  that  require 
attention;  first,  the  base  of  the  cyst  should  never  be  transfixed;  and, 
secondly,  no  attempt  at  dissection  should  be  made:  if  either  of  these 
cautions  be  neglected,  troublesome  hemorrhage  ma}'  ensue.  Xo  dressing 
is  required  after  the  operation  beyond  a  piece  of  diy  cotton  wool,  which 
may  be  laid  on  the  wound.  This  will  generally  heal  by  the  first  inten¬ 
tion.  Should  it  not  do  so,  water-dressing  should  be  applied.  When 
they  occur  upon  the  scalp,  a  large  number  of  these  tumors  ma}^  be 
removed  at  one  sitting ;  as,  however,  there  is  always  some  danger  of 
erysipelas  following  operations  in  this  situation,  it  is  only  prudent  to  t 
select  a  favorable  season  of  the  3^ear,  and  not  to  operate  if  the  health  be 
out  of  order.  Eiysipelas  is  the  only  danger  to  be  apprehended:  it  is 
especially  apt  to  occur  in  elderly  people  of  a  stout  make  and  florid  com- 


630 


TUMORS. 


plexion.  When  seated  about  the  back,  trunk,  or  limbs,  they  usually 
require  to  be  dissected  out,  being  thin  and  more  closely  incorporated 
with  the  skin,  and  often,  in  consequence  of  former  inflammation,  adhe¬ 
rent  to  the  subjacent  parts.  In  doing  this,  care  should  be  taken  that 
the  whole  of  the  cyst  is  extirpated ;  the  wound  should  be  dressed  lightly, 
and  speedily  heals.  If,  however,  any  portion  of  the  cyst  be  left,  it  should 
be  freely  rubbed  with  nitrate  of  silver,  lest  a  troublesome  fistula  remain. 
When  the  tumors  are  situated  between  the  shoulders  or  on  the  back,  and 
the  patient  is  unwilling  to  submit  to  an  operation,  I  have  sometimes 
easily  and  successfully  removed  them  by  opening  up  with  a  probe  the 
small  black  orifice,  which  will  alwa3^s  be  found  leading  into  them, 
squeezing  out  the  contents  of  the  cyst,  and  then  pushing  in  two  or  three 
silk  threads,  which,  acting  like  a  seton,  have  excited  the  requisite  amount 
of  inflammatory  action  to  bring  about  a  closure  of  the  C3^st. 

There  is  one  situation  in  which  these  cysts  are  often  met  with,  and 
where  their  removal  requires  special  care — viz.,  at  the  outer  angle  of  the 
orbit  in  children ;  here  they  are  apt  to  develop  shortly  after  birth,  and 
are  excessively  thin-walled,  requiring  a  careful  dissection  to  extirpate 
the  whole  of  the  cyst. 

The  horns  and  semi-malignant  ulcers  that  result  from  these  growths, 
may  require  excision.  If,  however,  the  ulceration  be  connected  with  < 
the  cranium  b^^  its  base  or  be  veiy  extensive,  as  in  the  case  depicted 
(Fig.  215),  it  will  be  safer  to  treat  it  by  the  application  of  the  chloride  of 
zinc,  or  by  occasionally"  touching  it  with  fused  potass. 

(5)  Various  forms  of  encysted  tumor  may  arise  from  the  Closure  and 
Dilatation  of  the  Ducts  of  other  Excretory  Organs;  as,  for  instance, 
encysted  hydrocele  from  the  closure  of  the  tubuli  testis,  or  cystic  tumors 
of  the  breast  from  the  obstruction  of  the  lacteal  ducts.  These  affections, 
however,  constitute  special  diseases,  the  consideration  of  which  must  be 
deferred  to  subsequent  chapters.  The  general  principle  of  Treatment  of 
such  diseases  consists  either  in  restoring  the  freedom  of  the  oulet  by  the 
excision  of  a  portion  of  the  wall,  or  obliterating  the  cyst  by  making  an 
incision  into  it,  and  allowing  it  to  granulate  from  the  bottom. 

(c)  Cy^sts  may  arise  from  the  Distension  of  Cavities  which  are  Unpro¬ 
vided  with,  any  Excretory  Duct;  as,  for  instance,  the  bursm;  which 
often  attain  a  veiy  considerable  size  in  these  circumstances.  The  struc¬ 
ture  of  these  cy^sts  becomes  greatly^  altered ;  sometimes  the  walls  are 
thin  and  expanded,  at  others  they  acquire  a  thick  cellulo-fibrous,  almost 
ligamentous  appearance.  Inside  they  are  often  warty-looking,  from  the 
deposition  of  imperfectly^  organized  fibrine,  often  arranged  in  a  lami¬ 
nated  form.  Not  unfrequently"  attached  to  the  walls,  and  floating  in 
the  interior,  are  a  number  of  granular  melon-seed-like  bodies,  grayish  or 
yellow  in  color,  semi-transparent,  elongated  or  irregular  in  shape, 
usually  rather  hard,  but  sometimes  soft  and  flocculent.  These  appear 
to  be  composed  of  masses  of  imperfectly  organized  fibrine,  somewhat 
resembling  in  structure  granulation-cells,  and  often  form  in  large  quan¬ 
tities,  so  as  to  block  up  the  interior  of  the  cyst,  converting  it  into  a  solid 
tumor.  The  fluid  contents  of  these  cysts  are  usually^  thin  and  serous, 
of  a  yellowish  or  brownish  color.  In  their  progress  these  cysts  are  found 
to  increase  up  to  a  certain  size,  when  they  usually  thicken  and  harden, 
in  consequence  of  fibrous  transformation  just  described;  or  else  they 
r  inflame  and  suppurate  in  an  unhealthy"  manner.  They  may  occur  in 
any  of  the  situations  in  which  bursae  naturally  exist  or  are  accidentally 
formed,  but  are  most  commonly"  met  with  upon  the  knee-cap,  the  nates, 
or  the  first  joints  of  the  great  toe. 


COMPOUND  CYSTS. 


631 


The  simple  forms  of  C3’stic  tumors  of  the  ovaiy  may  be  placed  under 
this  head,  as  they  arise  from  dilatation  of  the  Graafian  vesicles,  and  are 
filled  with  a  more  or  less  clear  serous  fluid.  The}^  sometimes  attain  an 
enormous  magnitude. 

The  Treatment  of  the  C3’sts  derived  from  bursse  consists  in  attempting 
their  absorption  by  the  use  of  stimulating  plasters ;  or,  if  this  fail,  in  the 
removal  of  their  contents  by  tapping.  Their  cavities  are  then  closed 
b3"  exciting  inflammation  and  suppuration  within  them,  by  the. introduc¬ 
tion  of  a  seton,  by  injection  wfith  stimulating  solutions,  or  by  the  subcu¬ 
taneous  section.  If  these  means  fail,  excision  will  be  required,  more 
especiall3^  if  the  tumor  have  become  dense  and  fibrous. 

2.  Cysts  occasionally  are  met  with  as  New  Formations^  filling  by  their 
own  secretion.  The3"  occur  in  the  general  areolar  tissue,  and  in  connec¬ 
tion  with  the  sheaths  of  tendons ;  but  most  frequentl3^  about  the  genera¬ 
tive  organs,  more  especiall3’’  in  the  ovaiy,  in  the  broad  ligament  of  the 
uterus,  or  in  the  breast.  These  C3"sts  vaiy  most  widel3’  in  size,  from  that 
of  a  millet-seed  to  tumors  weighing  man3^  pounds,  and  filling  up  the 
greater  part  of  the  abdominal  cavit3".  When  small,  they  are  usually 
thin-walled,  and  are  often  imbedded  in  a  matrix  composed  of  imperfect 
h3q3ertroph3"  of  the  organ  in  which  the3"  are  situated,  as  in  the  breasts 
and  testes  ;  when  large,  as  in  the  ovaiy,  the  walls  are  thick,  firm,  satiny, 
and  often  very  tough.  Projecting  into  their  interior  are  solid  masses, 
consisting  of  cauliflow^er-like  growths,  occasionall3’'  filling  up  the  whole 
inside  of  the  cyst  with  compact  solid  white  la3’ers.  These  “  intrac3’stic” 
growths  cause  by  their  increase  in  size  the  gradual  absorption  of  the 
more  fluid  contents,  until,  at  last,  their  development  is  arrested  by  the 
C3'st-wall. 

These  C3"sts  may  be  divided  into  the  simple  and  the  compound.  The 
Simple.,  or,  as  the3"  are  commonl3"  called.  Serous  Cysts,  are  met  with  in 
almost  eveiy  situation,  being  composed  of  a  thin  expanded  wall,  con¬ 
taining  a  slightly  viscid  serous  fluid. 

The  Compound,  or,  as  the3"  are  often  called.  Proliferous  or  3Iultilocular 
Cysts,  are  especiall3"  met  wfith  in  the  ovaiy,  and  have  been  studied  with 
great  care  b3"  Hodgkin,  and  more  recentl3"  133’’  Wilson  Fox.  Of  these 
there  are  two  varieties,  the  first  consisting  of  an  aggregation  of  simple 
C3"sts  closel3'  packed  and  pressed  together  ;  the  second  composed  of 
cvsts  having  others  o-rowinsf  from  their  walls.  The  cavities  of  these 
multilocuhir  C3"sts  present  the  greatest  possible  variety  in  their  con¬ 
tents  ;  fluid,  from  a  limpid  serum  to  a  semi-solid  jell3'-like  matter,  and  of 
eveiy  shade,  from  light  3'ellow  to  greenish-black  or  dark  brown,  is  met 
with  in  them  :  solid  intracystic  growths,  cancerous  masses,  or  the  debris 
of  epithelial  and  cutaneous  structures,  are  also  found  in  them. 

Wilson  Fox  has  shown  that  these  secondaiy  C3'sts  are  the  results  of 
constrictions  of  portions  of  the  ducts  of  glandular  structures,  associated 
with  the  h3’pertroph3'  and  fresh  growth  of  tubular  formations  ;  a  view 
which  satisfactoril3^  explains  the  occurrence  of  epithelium  and  other 
adenoid  structures  within  them.  Some  of  the  secondary  C3^sts  asso¬ 
ciated  with  the  papillaiy  growths  appear  to  result  from  the  cohesion  of 
adjoining  masses  of  papillaiy  structure,  and  thus  present  cavities  lined 
with  epithelium,  similar  to  that  which  lines  the  parent  cyst  and  the  papil¬ 
lary  mass  itself.  The  intrac3’stic  growths  themselves  appear  to  be  derived 
from  the  superficial  strata  of  the  stroma  of  the  C3’st-wall,  and,  as  they 
arise  by  protrusion  into  the  cavit3'  of  the  cyst,  the3"  are  necessarily 
covered  b3^  the  same  epithelium  which  lines  the  latter. 


632 


TUMOES. 


( 


Villous  growths  are  also  found  scattered  in  patches  on  the  inner 
surface  of  the  cj^st-wall.  They  are  always  highly  vascular,  consisting 
almost  entirel}"  of  loops  of  vessels  covered  by  a  layer  of  epithelium. 
These  are  intimately  connected  with  the  development  of  gland-struc¬ 
tures. 

The  Sanguineous  Cyst^ov  Hsematoina^is  a  peculiar  variety  of  the  simple 
form,  and  has  been  described  by  Paget  as  principally  occurring  about 
the  neck,  the  parotid,  the  anterior  part  of  the  thigh,  the  leg,  the  shoulder, 
and  the  pubes.  It  is  especially  characterized  by  containing  fluid  blood, 
more  or  less  altered  in  appearance.  He  describes  these  cysts  as  being 
formed  in  three  possible  ways;  either  b}’^  hemorrhage  into  a  previously 
existing  serous  cyst,  by  transformation  from  a  nsevus,  or  by  a  vein 
becoming  occluded  and  dilating  into  a  cyst.  I  have  seen  a  large 
hmmatoma  on  each  ear  of  a  lunatic.  The  contents  were  semi-solid 
coagulum.  These  sanguineous  cysts  may  sometimes  resemble  in  general 
appearance  encephaloid  disease.  A  case  of  this  kind  was  sent  to  me  b\' 
Henry  Bennett — a  tumor  of  about  the  size  of  an  orange,  of  nodulated 
appearance,  existing  in  the  leg  of  a  woman  below  the  knee,  where  it  had 
been  gradually  increasing  in  size  for  about  a  couple  of  years.  So  close 
was  the  resemblance  to  malignant  disease  presented  by  the  tumor,  that 
the  limb  had  been  condemned  for  amputation  by  some  Surgeons  who  had 
previously  seen  the  case ;  as,  however,  the  growth,  on  examination, 
proved  to  be  a  sanguineous  cyst,  as  its  walls  were  thin  and  adherent, 
and  as  it  extended  too  deeply  into  the  ham  to  admit  of  ready  removal,  I 
reduced  it  by  successive  tappings,  and  then,  laying  it  open,  allowed  it  to 
granulate  from  the  bottom.  When  practical,  however,  the  cysts 
should  always  be  dissected  out. 

Encysted  Tumor's^  containing  Hair  and  Fatty  Matters  (Pilo-cystic 
Tumors^  or  Dermoid  Gysts)^  are  occasionally  met  with.  These  would, 
in  many  instances,  appear  to  be  the  remains  of  blighted  ova  inclosed  in 
the  body,  as  they  are  congenital,  and  usually  contain  some  foetal  debris^ 
such  as  portions  of  bone,  teeth,  &c.  The  hairs  in  these  tumors  are  con¬ 
nected  with,  and  grow  from,  cuticular  structures  in  which  sebaceous 
follicles  are  commonly  distinctly  observable.  The  fatty  matter  which 
they  contain  in  large  quantity,  and  which  ma}''  either  be  solid  or  per¬ 
fectly  fluid,  is  in  all  probability  the  result  of  fatty  degeneration  of  the 
soft  tissues  of  wdiich  they  are  composed.  These  tumors  are  most 
frequentl}'  met  with  in  the  abdomen,  especially  about  the  ovaries, 
mesenteiy,  and  omentum  :  they  have  also  been  observed  in  connection 
with  the  testis,  having  probably  descended  into  the  scrotum  with  this 
gland.  A  very  remarkable  case  of  this  kind  once  occurred  at  University 
College  Hospital  under  Marshall.  They  have  also  been  found  about  the 
face,  wdthin  the  skull,  and  in  the  lung,  but  never,  I  believe,  in  connection 
with  the  extremities. 

Cysts  containing  fatty  matters  present  several  varieties.  The  con¬ 
tents  may  be  derived  from  the  fatty  degeneration  of  epithelial  structures, 
or  of  the  contents  of  a  cyst  originating  in  any  of  the  ways  above 
described.  Sometimes  the  fatty  matters  are  in  the  form  of  a  half¬ 
fluid,  oily  emulsion,  or  of  a  white  chees}^  mass  of  the  consistence  of 
soft  putty ;  at  others  they  present  a  very  peculiar  appearance  known  as 
Cholesteatoma,  {Perlgeschwidst^  Tumeur  Perlee).  This  consists  of  a 
smooth,  laminated,  white  and  dry  fatty  mass,  contained  in  a  cyst,  and 
composed  partly  of  concentrically  arranged  epithelial  cells,  and  partly 
of  crystalline  fat  and  cholesterine.  Yirchow’  has  described  this  as  a 


COXDYLOMATA. 


aoo 
voo 

distinct  variety  of  tumor,  and  considers  that  it  is  not  necessarily 
connected  with  epithelial  formations.  It  usually  occurs  in  the  temporal 
bone,  but  has  been  found  in  the  cerebellum.  It  is  a  very  rare  form  of 
tumor. 

II.— TUMORS  PRODUCED  BY  LOCAL  HYPERPLASIA  OF  COM¬ 
PLEX  STRUCTURES. 

These  tumors  differ  from  simple  hypertrophies  in  this,  that  there  is 
alwa3’s  some  departure  from  the  normal  tj^pe  of  form  in  the  part  affected, 
and  that,  although  the  individual  elements  remain  the  same,  the  propor¬ 
tion  existing  between  them  is  usually  modified. 

This  section  comprises  : — 1.  Tumors  connected  with  the  Integumental 
Structures,  as  Papillaiy  and  Wartj"  Growths,  and  Simple  Poh^pi ; 
2.  Lobular  H^qoertrophy  with  more  or  less  modification  of  Glandular 
Structures — (a)  in  the  Skin  and  Mucous  Membrane,  (b)  in  the  Breast, 
Testis,  (fee.;  3.  Vascular  Tumors  ;  4.  Tumors  of  Xerves;  5.  Tumors  of 
Muscle. 

1.  Tumors  connected  luith  the  Integumental  Structures,  ichether 
Mucous  or  Cutaneous. — The  simplest  of  these  formations  are  Corns, 
which  consist  merely  of  an  undue  development  of  cuticle,  with  a  slight 
increase  in  the  vascularity"  of  the  subjacent  cutis ;  subsequently^  the 
papillm  themselves  become  enlarged,  especially  when  the  irritation  has 
been  prolonged  or  considerable. 

Warts  are  the  result  of  a  primaiy  hypertrophy  of  the  papillm,  accom¬ 
panied  by  the  formation  of  new  vessels,  and  leading  to  a  great  increase 
in  the  development  of  the  epidermis,  which  forms  horny-  laminated 
strata,  and  sometimes  produces  masses  with  a  concentric  arrangement 
of  the  cells,  closely  resembling  the  net-like  structures  seen  in  epithe¬ 
lioma.  The  true  warts  are  most  commonly  found  on  the  skin,  and  are 
then  often  very  hard  and  horny-.  Softer  varieties  are,  however,  found 
on  the  muco-cutaneous  surfaces,  especially  of  the  prepuce  and  vulva, 
and  are  usually-  of  a  specific  origin ;  they  often  present  a  mixed  charac¬ 
ter  and  tend  to  pass  insensibly’’  into  the  next  group.  Warts  may  be  the 
result  of  a  local  irritation,  but  in  many  cases  they^  appear  to  depend  as 
much  upon  some  constitutional  condition. 

Condylomata  and  Mucous  Tubercles  present  a  still  greater  departure 
from  the  normal  condition  of  the  part,  and  are  considered  by-  some  as 
belonging  to  a  different  class  of  formations,  the  sarcomata.  The  papillm 
are  not  simply  hypertrophied,  but  present  some  modifications  in  their 
anatomical  structure,  the  fibrous  tissue  of  the  corium  being  softer,  and 
containing  a  greater  proportion  of  cells  and  nuclei.  It  is,  however,  con¬ 
venient  to  retain  them  under  the  present  head,  because  we  find  a  veiy 
gradual  transition  from  the  true  wart  to  the  most  truly-  sarcomatous  pa¬ 
pilloma,  as  these  formations  are  often  termed.  They-  occur  on  the  mucous 
or  muco-cutaneous  surfaces,  and  have  usually^  a  specific  origin.  When 
situated  on  the  mucous  membrane,  they-  are  often  pointed,  somewhat 
pendulous  or  nodulated  on  the  surface,  very  vascular,  and  bleed  readily^ 
when  touched ;  but  when  they-  occur  on  a  muco-cutaneous  surface,  they 
are  flattened,  expanded,  soft,  and  white,  constituting  the  true  condylo¬ 
mata  or  mucous  tubercles. 

Allied  in  structure  to  these  latter  growths,  though  probably-  truly 
belonging  to  the  next  class,  is  a  peculiar  pinkish-white  fibro-vascular 
tissue,  which  is  occasionally’  met  with  in  old  cicatrices,  more  especially 


634 


TUMORS. 


after  burns,  as  an  out-growth  of  these,  and  not  unfrequently  recurs  after 
removal ;  this  disease  is  termed  Cheloid  (see  p.  225). 

The  general  principles  of  Treatment  of  these  affections  consist  in 
their  removal  by  excision,  ligature,  or  caustics,  according  to  their  size, 
situation,  and  attachments.  Excision  is  usually  preferable  when  they 
are  seated  on  mucous  surfaces  ;  the  ligature  should  be  used  if  they  be 
large  and  pendulous ;  and  caustics  should  be  employed  when  they  are 
seated  on  the  skin  or  a  muco-cutaneous  surface. 

Polypi  are  pendulous  masses  growing  from  any  mucous  surface,  but 
more  especiall}^  from  the  nose,  ear,  throat,  uterus,  and  rectum.  The 
term  polypus  is  applied  very  indiscriminately  to  various  pendulous 
tumors  growing  from  mucous  membranes,  some  of  which  belong  to  the 
present  class,  whilst  others  belong  to  the  sarcomata.  The  true  mucous 
or  gelatinous  polypus  is  composed  of  the  elements  of  mucous  membrane 
expanded  and  spread  out,  and  consists  of  a  loose  fibrous  stroma  covered 
by  epithelium  more  or  less  distinctly  ciliated,  the  cilia  being  often  beau¬ 
tifully  seen  when  recent  specimens  are  examined  under  the  microscope. 
The  so-called  fibrous  or  medullary  pol3^pus  consists  of  other  forms  of 
tumor  growing  from,  and  covered  b}',  mucous  membrane.  The  true  mu¬ 
cous  pol^qDus  grows  rapidly,  being  a  soft  and  vascular  reddish-purple 
or  brown-looking  mass,  and  may  expand  greatly,  giving  rise  to  serious 
s^^mptoms  of  obstruction  in  the  passage  in  which  it  is  situate,  bleeding 
freely  when  touched,  destroying  the  bones  by  its  pressure,  and  producing 
great  mischief  and  disfigurement.  It  is  especially  in  the  nose  and  the 
uterus  that  it  attains  to  a  large  and  dangerous  size.  The  Treatment 
consists  in  removing  it,  according  to  its  situation,  its  degree  of  vascularity, 
and  the  nature  of  its  attachment,  by  avulsion,  ligature,  or  excision. 

2.  Hypertrophy  of  Glandular  Structures. — This  forms  an  important 
series  of  special  affections,  occurring  {a)  in  the  Small  Glands  of  the 
Skin  and  Mucous  Membrane,  or  (b)  in  the  Larger  Glands  which  consti¬ 
tute  individual  organs. 

The  part  becomes  chronically  enlarged  and  indurated,  usually  without 
any  signs  of  infiammatory  action,  though  in  some  cases  apparently  as 
the  result  of  this  condition.  On  examination,  the  structure  of  the  gland 
or  lobule  affected  will  either  be  found  to  have  undergone  an  imperfect  or 
ill-developed  hypertrophy  in  some  of  its  lobules,  or  to  be  expanded  by 
the  accumulation  of  glandular  epithelium,  which  will  be  found  in  many 
cases  to  have  undergone  degeneration,  and  to  have  given  rise  to  cheesy 
masses,  which  may  be  mistaken  for  tulDerculous  deposits. 

In  the  skin  and  mucous  membrane  these  formations  are  usually  accom¬ 
panied  by  an  increased  growth  of  the  papillae,  and  are  often  mistaken  for 
epithelioma;  this  error  is  the  more  likely  to  arise,  as  it  is  not  uncommon 
to  find  veiy  well  marked  nests  of  flattened  epithelial  cells  produced  in 
the  distended  extremities  of  the  gland-ducts.  I  have  removed  such  a 
growth  from  the  lip  under  the  impression  that  it  was  truly  epithelioma- 
tous  in  character;  but  it  proved,  on  careful  microscopic  examination,  to 
be  of  a  glandular  origin.  Though  purely  local  in  their  origin,  these 
tumors  often  produce  troublesome  ulceration,  and  may  even  return  in 
the  adjacent  parts  after  removal  by  the  knife ;  they  probably  never  give 
rise  to  secondary  formations  in  other  organs. 

Glandular  tumors  in  such  organs  as  the  breast,  testis,  etc.,  usually 
appear  as  distinctly  circumscribed  masses  affecting  one  or  more  lobules. 
The  special  features,  however,  presented  by  these  growths  will  be  con¬ 
sidered  when  we  come  to  the  diseases  of  the  organs  themselves. 


TUMORS  OF  THE  CONNECTIVE  TISSUE  TYPE.  635 


The  Treatment  of  these  tumors  consists  in  an  endeavor  to  remove  the 
mass  b}’  friction  with  the  preparations  of  iodine,  or  by  the  application 
of  stimulating  and  absorbent  plasters.  If  these  means  fail,  methodical 
pressure  may  sometimes  advantageously  be  employed ;  and,  as  a  last 
resource,  extirpation  b}’’  the  knife  must  be  performed. 

Tumors  specially  connected  with  (3)  the  Lymphatic  Tissue,  as  lym- 
phadenomo  ;  (4)  the  Vascular  Tissue,  as  aneurism  b}- anastomosis  ;  (5)  the 
Nervous  Tissue,  as  some  kinds  of  neuroma  ;  and  (6)  Muscular  Tissue, 
if  these  really  exist,  may  be  more  conveniently  studied  in  the  Chapters 
devoted  to  the  consideration  of  the  structures  to  which  they  belong ; 
and  it  will  be  sufficient  for  the  present  to  indicate  their  existence  in  con¬ 
nection  with  this  group.  Some  tumors  composed  of  osseous  tissue,  as 
simple  exostosis,  really  belong  to  this  group,  but  have  been  placed  in 
the  next  class  to  indicate  their  other  more  important  affinities. 

III.— TUMORS  OF  THE  CONNECTIVE  TISSUE  TYPE. 

This  class  constitutes  the  largest  and  possibly  the  most  important 
group  of  new  formations  with  which  the  Surgeon  has  to  deal,  and  con¬ 
tains  individuals  which  differ  most  widel}"  in  their  clinical  characters, 
but  which  are  nevertheless  closel}’  united  b}"  structural  and  develop¬ 
mental  affinities.  The  type  upon  which  this  class  is  founded  has  been 
explained  above,  and  in  considering  the  growths  derived  from  it  we  shall 
pass  from  the  most  homologous  to  the  most  heterologous. 

1.  Those  derived  directly  from  Connective  Tissue;  (a)  Fatty  Tumors, 
Lipoma ;  {h)  Fibroid  Tumors  (simple) ;  (c)  The  Sarcomata,  consisting 
of  Areolar,  Fibro-cellular,  Myxomatous,  and  Recurrent  Fibroid  Tumors  ; 
(d)  Fibro-plastic  and  Mj’eloid  Tumors  ;  (e)  Granulation  Tumors. 

2.  Those  derived  from  or  formed  upon  the  tj^pe  of  Cartilage  ;  Enchon- 
droma. 

3.  Those  derived  from  or  formed  upon  the  tj’pe  of  Bone;  (a)  Exos¬ 
tosis;  (b)  Osteo-Sarcoma;  (c)  Malignant  Osteoid. 

1.  Tumors  derived  directly  from  Connective  Tissue. — a. 
Fatty  Tumors  constitute  an  important  class  of  surgical  diseases,  as  they 
occur  very  extensively^  in  almost  every  part  of  the  body",  and  at  all  ages, 
though  they-  are  most  commonly  met  with  about  the  earlier  periods  of 
middle  life.  In  the  majority  of  cases  they"  appear  to  originate  without 
any-  evident  cause  :  in  other  instances  they  can  be  distinctly  traced  to 
pressure  or  to  some  local  irritation,  as  to  that  of  braces  or  shoulder- 
straps  over  the  back  and  shoulders.  In  one  case  I  have  known  the 
disease  to  be  hereditarily  transmitted  to  the  members  of  three  genera¬ 
tions  of  a  family. 

Fatty  accumulations  take  place  under  two  forms,  one  diffused,  the 
other  circumscribed ;  it  is  the  latter  variety"  only-  that  is  termed  the  Adi¬ 
pose  Tumor.  The  diffused  form  of  fatty"  deposition  occurs  in  masses 
about  the  chin  or  nates  without  constituting  a  disease,  though  it  may 
occasion  much  disfigurement. 

Fatty"  or  adipose  tumors  may"  form  in  all  parts  of  the  body  as  soft, 
indolent,  inelastic,  and  doughy"  swellings,  growing  but  very"  slowly; 
being  either  oval  or  round,  but  not  unfrequently-  lobulated,  and  occur¬ 
ring  most  frequently"  in  the  subcutaneous  fat  about  the  neck  and  shoulders, 
but  occasionally"  met  with  between  the  muscles,  in  the  neighborhood  of 
joints,  of  serous  membranes,  as  of  the  pleura  and  of  mucous  canals, 
sometimes  in  very  unusual  situations  where  such  growths  would  scarcely 


636 


TUMORS. 


be  looked  for.  Thus  I  removed  some  time  since  a  lipoma  three  inches 
in  length,  and  as  thick  as  the  thumb,  from  under  the  annular  ligament 
and  the  palmar  fascia  of  a  young  woman,  where  it  lay  in  close  contact 
with  the  ulnar  arteiy  and  nerve.  A  very  curious  circumstance  connected 
with  these  tumors  is  that  they  occasionally  shift  their  seat,  slowly 
gliding  for  some  distance  from  the  original  spot  on  which  they  grew; 
thus  Paget  relates  cases  in  which  fatt}'  tumors  shifted  their  position 
from  the  groin  to  the  perinseum  or  the  thigh.  I  have  known  one  to  de¬ 
scend  from  the  shoulder  to  the  breast. 

They  may  attain  a  large  size,  but  onlj^  occasion  inconvenience  by  their 
pressure  or  bulk :  sometimes  the}’  appear  in  great  numbers,  upwards  of 
250  tumors  of  various  sizes  having  been  found  in  the  same  individual. 
The}’  rarely  ulcerate  or  inflame,  nor  do  they  undergo  any  ulterior  changes 
of  structure. 

The  typical  Lipoma  is  a  mass  of  yellow  oily  fatty  matter  and  areolar 
tissue,  inclosed  in  a  fine  thin  capsule  having  small  vessels  ramifying  over 
its  surface.  This  tumor  is  usually  more  or  less  lobulated,  often  remarka¬ 
bly  dentated,  and  sending  out  irregular  prolongations  that  extend  to 
some  little  distance  into  the  surrounding  cellulo-adipose  tissue. 

These  tumors,  which  present  the  least  deviation  from  the  normal 
structure,  are  derived  from  the  ordinary  connective  tissue  by  an  increased 
development  of  oily  matter  in  the  cells  of  the  part.  They  present  certain 
minor  varieties  in  their  structure,  dependent  upon  the  proportion  of  the 
true  fatty  to  the  fibrous  elements.  Their  microscopic  characters  are 
those  of  ordinary  adipose  tissue,  but  it  is  not  uncommon  to  find  crystal¬ 
line  deposits  of  the  fatty  acids  in  the  cells. 

In  the  Treatment  of  fatty  tumors,  little  can  be  done  except  by  extirpa¬ 
tion  with  the  knife,  by  which  the  patient  is  speedily  and  effectually  rid 
of  the  disease.  The  tumor,  being  encapsuled  and  but  loosely  adherent 
to  adjacent  parts,  readily  turns  out,  and  the  wound  often  heals  by  the 
first  intention.  It  is  true  that  we  have  the  sanction  of  Sir  B.  Brodie’s 
high  authority  for  the  administration  of  the  liquor  potassae  in  some 
cases,  under  which  treatment  this  eminent  Surgeon  states  that  fatty 
tumors  have  occasionally  disappeared. 

h.  Fibroid  Tumors. — These  growths  are  by  no  means  so  common  as 
many  of  the  affections  that  have  already  been  described  ;  they  are  met 
with  in  various  situations,  as  in  the  testes  and  mamma,  uterus  and 
antrum,  about  joints,  in  the  periosteum,  in  the  subcutaneous  areolar  tis¬ 
sue,  and  in  connection  with  nerves.  The  situations  in  which  they  are 
most  frequent,  and  where  their  structure  is  most  typical,  is  in  the  neck, 
especially  in  the  parotid  region,  in  the  uterus,  and  the  antrum.  In  shape 
these  tumors  are  irregularly  oval  or  rounded  ;  they  are  smooth,  painless, 
and  movable  ;  they  grow  slowly,  but  may  attain  an  enormous  size,  equal 
to  that  of  a  cocoa-nut  or  water-melon.  Liston  removed  from  the  neck 
one,  which  is  at  present  in  the  Museum  of  the  College  of  Surgeons,  that 
weighed  twelve  pounds  ;  they  have,  however,  been  found  weighing  as 
mucli  as  seventy  pounds.  They  are  almost  invariably  single,  and  when 
cut  into,  present  a  white  glistening  fibrous  structure,  being  composed  of 
nucleated  fibres  like  those  of  ligamentous  tissue  (Fig.  216).  The  cells 
are  few  in  number,  elongated,  branched,  and  anastomosing.  These 
tumors  may  remain  stationary  for  years,  and  this  is  the  condition  in 
which  they  are  often  presented  to  the  Surgeon.  Eventually,  however, 
they  are  apt  to  undergo  disintegration,  becoming  infiltrated,  cedematous, 
and  softening  in  the  centre,  or  at  various  points  of  the  circumference ; 


SAKCOMATOUS  TUMOKS. 


637 


they  then  break  down  into  a  semi-fluid  mass,  the  integuments  covering 
them  inflame  and  slough,  and  an  unhealthy  pus,  mixed  with  disorganized 
portions  of  the  tumor,  is  poured 
out,  leaving  a  large  and  un¬ 
healthy  sloughy  chasm,  from 
which  fungous  sprouts  may 
shoot  up,  readily  bleeding  on  the 
slightest  touch,  and  giving  the 
part  a  malignant  appearance ; 
the  patient  eventually  falling 
into  a  cachectic  condition,  and 
becoming  exhausted  by  the  he¬ 
morrhage  and  discharges.  In 
other  cases  these  tumors  may 
degenerate  into  a  spongy  calca¬ 
reous  mass  of  a  brownish  color 
and  hard  consistence;  but  they 
never  undergo  proper  ossifica¬ 
tion.  More  rarely  the  interior 
of  these  growths  softens  and 
undergoes  absorption,  so  as  oc¬ 
casionally  to  form  cysts  of  large 
size,  containing  fluids  of  various 
shades  of  color.  Paget  relates  the  case  of  a  very  large  cyst  of  this  kind 
formed  by  the  hollowing  out  of  a  fibroid  tumor  of  the  uterus,  which  was 
twice  tapped  by  mistake  for  ovarian  dropsy. 

The  Treatment  of  these  tumors  is  in  a  great  measure  palliative  ;  but 
when  they  are  so  situated  as  to  admit  of  removal,  as  in  the  neck,  under 
the  angle  of  the  jaw,  or  in  the  antrum,  they  should  always  be  extirpated. 

The  Malignant  Fibroid  Tumor  closely  resembles  in  its  general  appear¬ 
ance  and  microscopic  elements  the  ordinary  fibroid  growths;  but  its 
great  characteristic  is  its  recurrence  after  removal,  with  much  tendency 
to  ulceration,  sloughing,  and  hemorrhage.  When  it  returns,  it  forms  not 
only  in  its  original  locality,  but  in  internal  parts  of  the  body  at  a  dis¬ 
tance  from  it. 

c.  Sarcomata. — This  group  is  less  defined,  and  the  name  has  been 
applied  rather  vaguely  by  several  writers;  of  late,  indeed,  the  term  sar¬ 
coma  has  included  all  the  forms  of  tumors  derived  from  the  connective 
tissue-,  not  excepting  even  the  fibro-plastic  or  myeloid  varieties.  It  seems, 
however,  desirable  to  restrict  the  name  to  the  group  now  under  considera¬ 
tion  ;  which,  although  presenting  vaiying  degrees  of  departure  from  the 
normal  t^’pe,  have  nevertheless  certain  very  important  features  in  com¬ 
mon.  These  common  characters  are  as  follows  :  an  intercellular  sub¬ 
stance,  presenting  a  certain  degree  of  fibrillation,  rarely  so  well  marked  as 
that  seen  in  normal  connective  tissue,  sometimes  indeed  very  imperfect ; 
it  is  usually  rather  soft,  and  often  contains  much  fluid  in  the  meshes  of 
the  stroma.  Imbedded  in  this  matrix  are  ceil  structures  varying  much 
in  number  and  size,  sometimes  thinl}’-  scattered,  elongated,  and  spindle- 
shaped,  sometimes  of  a  more  oval  or  caudate  form  and  collected  into 
small  groups.  Each  cell  usually  contains  a  single  well-defined  nucleus 
and  nucleolus  ;  sometimes,  however,  the  nucleus  so  completely  fills  the 
body  of  the  cell  that  it  is  not  easily  detected.  Any  two  individuals 
belonging  to  this  group  may  be  much  unlike,  and  it  is  only  by  com¬ 
paring  the  intermediate  forms  that  their  relation  to  one  another  can  be 
recognized. 


Fi£?.  216. 


Structure  of  Fibroid  Tumor. 


638 


TUMORS. 


The  Areolar  Tumors  are  little  more  than  a  simple  hyperplasia  of  the 
subcutaneous  or  submucous  areolar  tissue.  These  are  represented  by 
pendulous  sarcomatous  growths  forming  large  tumors  commonly  called 
IFens,  which  may  occur  on  any  part  of  the  surface.  The}"  are  smooth, 
pedunculated,  firm,  somewhat  doughy,  but  non-elastic,  pendulous,  and 
movable,  slowly  increasing  without  pain  often  to  a  very  great  size.  It 
is  in  warm  climates,  and  in  the  Hindoo  and  Negro  races,  that  they  attain 
their  greatest  development,  having  been  met  with  fifty,  seventy,  and  even 
a  hundred  pounds  in  w’eight.  They  are  chiefly  seated  about  the  genitals, 
enveloping  the  scrotum,  penis,  and  testes  in  the  male,  or  depending  from 
the  labia  of  the  female.  That  remarkable  enlargement  of  the  leg  occur¬ 
ring  in  the  Mauritius  and  some  parts  of  the  West  Indies,  and  hence 
termed  Barbadoes  leg,  is  an  affection  of  this  kind.  In  structure  these 
growths  appear  to  be  a  simple  hypertrophy  of  the  fibro-cellular  element 
of  the  part  affected,  being  composed  of  a  loose,  reddish  stroma  moistened 
with  a  serous  fluid.  In  the  Treatment  of  these  affections,  pressure  and 
iodine  applications  may  be  tried  in  the  earlier  stages,  with  the  view,  if 
possible,  of  checking  their  growTh  ;  at  a  later  period  they  must,  if  large, 
l3e  removed  by  operation,  though  this  procedure  is  at  times  an  extremely 
severe  one,  owing  to  their  great  size. 

The  Fibro  Cellular  Tumors^  described  cursorily,  by  many  writers,  as 
ceZZw/ar  tumors,  have  been  more  fully  examined  by  Paget.  They  are  not 
of  common  occurrence ;  and  when  met  with  they  are  most  frequently 
found  in  the  scrotum,  the  labium,  the  deep  muscular  interspaces  of  the 
thigh  or  axillary,  and  on  the  scalp,  in  w"hich  situation  they  may  form 

large  masses,  attaining  sometimes  to  a  weight 
of  many  pounds.  The  accompanying  Figure 
(217)  is  taken  from  a  tumor  of  this  kind, 
which  I  removed  from  the  side  of  a  woman. 
I  have  removed  one  weighing  nearly  four 
pounds  from  the  axilla  of  a  woman  where  it 
lay  between  the  serratus  magnus  and  the  ribs, 
forming  a  tumor  of  great  size.  When  they 
occur  about  the  scrotum  and  labium,  these 
tumors  must  not  be  confounded  with  elephan¬ 
tiasis  of  these  parts,  from  which  they  may  be 
distinguished  by  being  limited  and  circum¬ 
scribed  masses,  and  not  mere  outgrowths. 
Paget  observes  that  when  occurring  about  the 
genital  organs  they  happen  in  young  w'omen 
and  in  old  men.  They  happen  only  in  adults 
who  otherwise  are  in  good  health,  and  grow 
quickly,  forming  soft,  elastic,  rounded,  and 
smooth  tumors ;  they  are  not  attended  by  any 
pain.  After  removal  they  are  found  to  possess 
a  thin  capsule,  to  be  of  a  yellowish  color,  and 
to  contain  a  large  quantity  of  infiltrated  sero- 
plastic  fluid,  which  may  be  squeezed  out  abun¬ 
dantly,  and  coagulates  on  standing.  Under 
the  microscope  they  display  a  fine  areolar  stroma,  consisting  of  undula¬ 
ting  filaments  or  fibrous  bands,  in  the  midst  of  which  abundant  nuclei 
appear,  which  are  rendered  more  distinct  by  the  action  of  acetic  acid. 
Elongated  fibre-cells  are  also  to  be  seen  scattered  amongst  the  fibres. 
They  will  sometimes  appear  to  grow  rapidly,  when,  in  reality,  the  increase 
in  size  is  due  to  a  rapid  increase  of  the  fluid,  and  not  to  a  new  deposit  of 


Fig.  217. 


Pendulous  Fibro-cellular  Tumor. 


EECURRING  FIBROID  TUMOR. 


639 


a  solid  character  on  the  tumor.  As  these  tumors  are  perfectly  innocent, 
no  hesitation  need  he  entertained  about  their  removal. 

Closely  allied  to  these  last  in  nature  and  origin,  but  presenting  some 
special  characters  and  representing  a  still  greater  departure  from  the 
normal  standard,  are  the  formations  called  by  Yirchow  Glioma  and 
Myxoma.  Glioma  arises  from  the  neuroglia  or  delicate  connective  tissue 
of  the  brain  and  retina,  and  in  it  the  cells  bear  a  greater  proportion  to 
the  intercellular  substance  than  in  anj’  of  the  growths  above  described. 
Myxoma  presents  a  still  greater 
excess  of  cell-structures,  the  inter¬ 
cellular  substance  being  remarka¬ 
bly  soft,  and  yielding  mucine  in¬ 
stead  of  gelatine  on  boiling.  The 
structure  is  very  similar  to  that 
of  the  umbilical  cord.  It  consti¬ 
tutes  some  forms  of  soft  mucous 
polypi.  The  accompanying  draw¬ 
ing  (Fig.  218)  was  taken  from  a 
myxoma  which  I  removed  from 
over  the  parotid  gland  of  a  man 
aged  47.  Myxoma  may  attain  an 
enormous  size.  I  have  lately  had 
under  my  care  a  gentleman  45 
years  old,  in  wdiose  abdomen  a 
tumor  developed  which  attained 
a  great  magnitude.  After  death 
it  weighed  at  least  50  pounds, 
and  was  found  on  examination  by 
Mr.  Beck  to  be  true  myxoma  with  much  true  fat  deposited  in  layers 
throughout  its  substance. 

In  some  cases,  especially  in  Parotid  Tumors,  myxoma  is  found  asso¬ 
ciated  wdth  Enchondroma. 

The  Recurring  Fibroid  Tumor  may  be  considered  as  standing  at  the 
extreme  end  of  the  list  of  the  sarcomata,  and  as  presenting  many  cha¬ 
racters  which  connect  it  with  the  true  fibro-plastic  or  myeloid  type. 
Here  the  cells  are  numerous  and  constitute  a  very  large  proportion  of 
the  tumor  ;  the  intercellular  substance  is  very  imperfectly  fibrillated, 
usually  granular  and  containing  nuclei.  The  cells  are  elongated,  fusi¬ 
form,  or  branched,  and  usually  each  contain  a  single  distinct  nucleus. 
It  is  described  by  Paget  as  closely  resembling  in  general  aspect  the  com¬ 
mon  fibroid  tumor,  w’hilst  in  its  microscopic  structure  it  is  very  like  the 
fibro-plastic  tumor,  its  most  marked  character  being  its  tendency  to  recur 
after  removal.  Of  this  peculiar  and  hitherto  undescribed  disease  he 
relates  several  cases.  One  was  a  tumor  of  the  upper  part  of  the  leg, 
which  between  1846  and  the  end  of  1848  had  been  removed  five  times, 
and  reappeared  for  the  sixth  time  after  the  last  operation,  when,  as  it 
had  become  large  and  ulcerated,  amputation  was  deemed  advisable  ;  this 
procedure,  however,  was  followed  by  death.  The  examination  of  the 
third  tumor  presented  “  very  narrow,  elongated,  caudate,  and  dat-shaped 
nucleated  cells,  many  of  which  had  long  and  subdivided  terminal  pro¬ 
cesses  in  the  last  removed  tumor,  the  cells  were  generally  filled  with 
minute  shining  molecules,  as  if  fatty  degeneration  had  taken  place.  In 
another  case  a  tumor  of  the  shoulder  had  been  removed,  and  returned 
four  times  between  Ma}^,  1843,  and  December,  1849,  reappearing  in  the 
following  year  for  the  fifth  time ;  it,  however,  after  a  time  became'  sta- 


Fig.  218. 


640 


TUMORS. 


tionaiy,  and  many  years  afterwards  the  patient,  but  for  the  presence  of 
the  tumor,  might  be  considered  to  be  a  strong  and  healthy  man.  Paget 
also  relates  a  case  in  which,  between  1839  and  1851,  Syme  removed  a 
tumor  of  this  kind  five  times  from  the  upper  part  of  the  chest ;  it  recur¬ 
red  a  sixth  time  and  was  followed  by  death.  He  also  refers  to  a  case 
b}'  Gluge,  in  which  a  similar  tumor  was  five  times  removed  from  the 
scapula,  its  sixth  reappearance  being  followed  b}-  death.  The  most 
interesting  of  all  is  a  case  by  Maclagan,  in  which  four  removals  were 
performed  in  the  course  of  thirty-six  years,  twenty-three  years  intervening 
between  the  second  and  third  removals,  and  eleven  between  the  third  and 
fourth.  Since  this  form  of  tumor  was  first  described  b}^  Paget,  a  num¬ 
ber  of  instances  have  been  recorded  by  British  and  continental  Surgeons. 
These  recurrent  tumors  appear  to  become  more  malignant  in  the  latter 
than  in  the  earlier  recurrences,  becoming  more  painful,  rapidly  degene¬ 
rating,  and  giving  rise  to  an  ulcerating  fungus,  which  eventually  proves 
fatal  by  exhaustion  and  hemorrhage. 

The  sarcomata  have  all  more  or  less  a  tendency  to  local  recurrence, 
the  later  members  of  the  group  having  a  greater  tendency  than  the 
earlier  ones ;  but  they  infinitely  rarel3^,  if  ever,  appear  as  secondary 
deposits  in  internal  organs,  and  this  constitutes  an  important  distinc¬ 
tion  between  them  and  the  members  of  the  next  group.  It  must  be 
remembered,  however,  that  some  authors  applj^  the  term  “  sarcomata” 
to  all  the  connective  tissue  tumors. 

d.  Fihro-plastic  and  Myeloid  Tumors  unquestionably  give  rise  at 
times  to  secondary'  deposits  in  distant  parts,  and  have  a  very  remarka¬ 
ble  tendenc}'-  to  local  recurrence  unless  removed  at  an  early  period. 
These  tumors  present  themselves  under  two  forms  :  the  true  fibro-plasiic 
tumor^  consisting  almost  exclusively  of  elongated  fusiform  cells,  con¬ 
taining  for  the  most  part  a  single  oval  or  oat-shaped  nucleus  and 
nucleolus  (Fig.  219) — to  this  tumor  the  name  “spindle-celled  sarcoma” 


Fig.  219.  Fig.  220. 


Fusiform  ai^d  oat-shaped  Cells  from  Mye-  Kecurreut  Malignant  Xaral  Polypus:  Spindle-cells, 
loid  Tumor.  Myeloid  Sarcoma.  220  diameters. 


has  been  given ;  and  the  true  myeloid  tumor,  consisting  of  large  multi- 
nucleated  vesicular  or  plate-like  cells,  analogous  to  those  found  in  the 
foetal  marrow,  measuring  from  to  xoVo  inch  in  diameter,  and 

containing  from  two  to  twelve  oval  nuclei,  with  distinct  and  highly 
refracting  nucleoli.  These  two  forms  are  intimately  connected  together  ; 


FIBRO-PLASTIC  AXD  MYELOID  TUMORS. 


641 


so  much  so,  that  it  is  rave  to  find  a  tumor  which  does  not  present  some 
trace  of  transitional  structure,  and  it  is  not  uncommon  to  find  the 
myeloid  elements  appearing  in  greater  numbers  on  the  recurrence  of  the 
tumor.  An  important  character  of  these  growths  is  the  veiy  great 
proportion  which  the  cells  bear  to  the  intercellular  substance ;  the  latter 
is  often  scarcely  to  be  recognized,  being  represented  b}^  a  soft  colloid 
material,  with  here  and  there  fibrous  bands,  which  divide  the  cells  into 
groups,  and  give  the  tumor  a  lobulated  appearance,  Tliese  tumors  may 
be  found  in  connection  with  an}"  of  the  fibrous  membranes,  but  more 
especially  with  the  periosteum  ;  in  fact,  they  may  be  looked  upon  as 
periosteal  and  endosteal  tumors,  excellence.  It  is  probable  that  the 
myeloid  cells  never  occur  in  those  forms  which  are  unconnected  with 
bone ;  and  some  writers  have  attempted  to  dissociate  the  two  forms  of 
tumors,  and  to  describe  those  containing  the  true  myeloid  plates  under 
the  name  “  Tumeurs  Ji  Myeloplaxes”  (Eugene  Xelaton)  (Fig.  221).  That 
these  are,  however,  merely  varieties  of  the  same  formation,  the  following 
case,  which  occurred  under  my  care  at  University  College  Hospital, 
sufficiently  indicates.  A  tumor  as  large  as  a  full-sized  turnip  was  re- 
rfioved  from  the  shoulder  of  a  middle-aged  man,  and  was  found  to  be 
slightly  connected  wdth  the  spine  of  the  scapula.  On  examination,  it 


Fig.  221. 


.  Fig.  222. 


Myeloid  Plates  or  Plate-like  Cells  from  a 
Tumor  of  the  lo'^ver  end  of  the  Femur. 


Fihro-plastic  Tumor  springing  from  the 
Scapula. 


presented  all  the  naked  eye  and  microscopical  characters  of  a  fibro¬ 
plastic  growth,  consisting  almost  entirely  of  densely  packed  fusiform 
cells,  wdth  oval  or  oat-shaped  nuclei ;  some  few  oval  and  caudate  cells 
being  scattered  amongst  them  (Fig.  222).  A  small  mass  reappeared 
before  the  wound  had  completely  closed,  and  on  examination  presented 
a  much  larger  proportion  of  oval  and  caudate  cells  with  multiple  nuclei 
(Fig.  223).  It  recurred  a  second  time;  and  was  now’  found  to  consist 
almost  entirely  of  large  oval,  plate-like  or  flask-shaped  cells,  wdth  very 
numerous  nuclei,  wdiilst  comparatively  few  of  the  true  fibro-plastic  cells 
were  found  (Fig.  224).  A  portion  of  the  spine  of  the  scapula,  which 
w’as  removed  with  the  tumor,  showed  that  the  growth  had  sprung  from 
the  cancellous  structure  of  the  bone. 

Myeloid  tumor  was  first  fully  described  by  Lebert,  under  the  term 
'‘^fihro-jylastic^''’  and  is  probably  the  albuminous  sarcoma  of  Abernethy. 
Its  clinical  and  anatomical  characters  have  been  carefully  investigated 
by  Paget,  who  considers  it  as  intermediate  in  structure  between  the 
fibroid  and  fibro-cellular  forms.  It  is  found  about  the  jaws,  in  the 
bones,  the  hands  and  feet,  in  the  areolar  tissue  of  the  neck,  over  the 
VOL.  I. — 41 


642 


TUMORS. 


parotid,  in  the  mammary  gland,  and  frequently  in  connection  with  the 
mucous  cavities  and  canals,  as  in  the  rectum  and  nasal  fossa.  The 


Fig.  223. 


Cells  from  Fibro-plastic  Tumor  of  Scapula:  first 
Eecurrence. 


Fig.  224. 


Microscopic  Characters  of  the  Tumor 
in  its  second  Recurrence.  Multinucle- 
ated  Myeloid  Cells. 


tumor  presents  well-marked  physical  characters.  On  making  a  section, 
it  cuts  in  an  uniform,  smooth,  and  somewhat  elastic  manner;  it  is  semi¬ 
transparent,  sliining,  and  juic3’-lookiug,  of  a  greenish-graj',  bluish,  or 
pinkish-color,  like  the  albumen  of  some  birds’  eggs,  often  spotted 

or  stained  with  discolored 
Fig.  225.  marks,  varying  in  tint 

from  a  blood  to  a  pinkish, 
lirownish,  or  livid  red  hue, 
which,  if  extensive,  gives 
it  a  fleshy  look ;  its  struc¬ 
ture  is  usually-  brittle.  Af¬ 
ter  a  time  it  breaks  down 
in  the  interior  into  a  dark 
brown  grumous  glairy 
fluid,  contained  in  cj’sts 
formed  in  the  parenchyma  of  the  growth.  This  tumor  will  grow  to  a 
very  large  size,  sometimes  slowly  and  graduallj',  at  other  times  with 

very  great  rapidity  (Figs.  225, 


Myeloid  Tumor  of  Radios. 


Fig.  226. 


& 

226).  I  have  removed  it  from 
the  parotid  region  when  as  large 
as  the  flst,  and  from  the  breast 
weighing  as  much  as  six  pounds. 
It  most  commonly  occurs  in 
3’’Oung  people,  without  pain  and 
without  any  known  cause.  When 
developed  in  bone,  pulsation  will 
occasional!}'  be  felt  in  the  tumor, 
not  in  consequence  of  the  large 
size  of  its  own  bloodvessels,  but, 
as  Paget  has  observed,  from  the 
transmission  of  pulsation  to  it 
from  the  vessels  of  the  bone. 
In  the  majority  of  cases  it  may 
be  safely  removed  without  the  prospect  of  recurrence,  but  occasional!}', 
and  without  any  aj^parent  reason,  it  returns  after  removal.  Most 


Myeloid  Tumor  of  the  Metacarpal  Bones  of  the 
Index  and  Middle  Fingers.  Successful  Removal  of 
ihose  Bones  and  Fingers. 


ENCHONDROMA. 


643 


generally  it  is  distinctly  encapsuled  when  occurring  in  the  neck  and 
breast,  and  then  may  be  extirpated  with  ease  and  safety’’ ;  but  if  its 
degeneration  have  gone  on  to  infiltration  into  the  neighboring  struc¬ 
tures,  its  recurrence  will  speedih^  take  place.  Lebert  relates  six  cases 
of  this  disease  in  which  recurrence  took  place  after  operation  with 
secondary  deposits  in  internal  organs. 

e.  Granulation  Tumors. — Under  this  head  Virchow  has  classed 
several  remarkable  formations,  viz.,  the  Syphilitic  Tumors ;  whether 
affecting  the  entire  organ  as  in  syphilitic  sarcocele,  or  appearing  merely 
as  isolated  masses,  as  the  Gummy  Tumors  ;  Lupus,  and  its  allied  forms; 
Elephantiasis ;  and  the  products  of  Farcy.  These  he  considers  to  be 
connected  together  by  a  certain  similarity  of  structure,  which  resembles 
that  of  imperfectly  formed  connective  tissue.  Many  of  these  formations 
have  been  looked  upon  as  the  products  of  inflammation,  but  it  would 
appear  more  reasonable  to  consider  them  as  the  results  of  the  action  of  a 
specific  poison  upon  the  nutrition  of  the  areolar  tissue. 

2.  Tumors  derived  from  or  formed  upon  the  type  of  Car¬ 
tilage. — To  all  these  the  generic  term  Enchondroma  is  applied,  whether 
they  be  entirely  composed  of  a  substance  having  the  structures  of  true 
cartilage,  or  whether  this  constitute  only  a  portion  of  the  mass. 

Enchondroma  or  the  Cartilaginous  Tumor ^  carefully  studied  by  Miiller, 
and  investigated  by  Paget,  is  an  exceedingly  interesting  affection, 
whether  we  regard  the  peculiarity  of  its  structure,  its  comparatively 
frequent  occurrence,  or  the  large  size  that  it  occasionally’’  assumes.  It 
takes  place  under  two  distinct  forms ;  most  commonly  as  an  innocent 
growth,  but  in  other  cases  assuming  a  malignant  tendency  and  appear¬ 
ance.  These  two  forms  present  different  signs.  In  the  first  case,  the 
enchondroma  occurs  as  a  hard,  smooth,  elastic,  ovoid,  round,  or  flattened 
tumor,  of  small  or  but  of  moderate  size,  seldom  exceeding  that  of  an 
orange,  and  growing  slowly^  without  pain.  In  the  second  form,  it  ap¬ 
proaches  in  its  character  to  malignant  disease,  growing  with  extreme 
rapidity,  attaining  an  enormous  size  within  a  few  months,  and  contami¬ 
nating  the  sy^stem  by"  the  deposit  of  secondaiy  enchondromatous  growths 
in  internal  organs;  in  these  circumstances,  it  would  appear  to  have 
occasionally-  been  mistaken  for  the  rapidly  spreading  forms  of  encephaloid 
disease.  But,  although  they  occasionally"  assume  the  course  that  is 
usually’’  adopted  only  by^  true  malignant  growths,  enchondromata,  espe¬ 
cially"  of  the  testes,  are  not  unfrequently’’  associated  with  encephaloid  ; 
and  when  this  occurs,  the  secondary  deposits  are  usually  of  the  latter 
character  only",  being  in  rare  cases  of  a  mixed  nature. 

When  these  growths  attain  a  rather  large  size,  though  occasionally 
whilst  they  are  still  but  of  moderate  dimensions,  ossification  may  occur 
in  some  parts,  whilst  a  process  of  disintegration  may  take  place  in 
others,  which  soften,  break  down,  and  liquefy"  in  their  interior,  causing 
the  skin  covering  them  to  become  duskily  inflamed,  eventually  to  slough, 
and  to  form  fistulous  openings,  through  which  a  thin  jelly"-like  matter 
is  discharged.  In  some  cases  it  would  appear  that  large  tumors  of  this 
description,  softening  in  the  centre,  and  becoming  elastic  and  semi-fluc¬ 
tuating,  have  been  mistaken  for  cysts,  and  have  been  tapped  on  this 
supposition.  In  small  enchondromata  the  opposite  condition  more 
frequently  occurs,  the  tumor  becoming  indurated,  and  undergoing 
ossification. 

Microscopical  Characters. — Although  in  many  respects  the  structure 
closely  resembles  that  of  normal  cartilage,  and  especially  that  variety 
known  as  foetal  cartilage,  yet  there  are  certain  peculiarities  which  may 


644 


TUMORS. 


often  serve  to  clistinguisli  the  two.  In  the  more  t^^pical  forms  the  cells 
are  preternaturall}^  large  and  round,  whilst  in  other  cases  they  are 
irregularly  polygonal,  shrivelled  or  branched  ;  they  are  not,  as  a  rule, 

equally  distributed  through  the  matrix,  but 
are  collected  into  groups.  Their  diameter 
varies  from  to  of  an  inch,  and  they 
contain  a  single  large  nucleus  and  nucle¬ 
olus  (see  Fig.  221).  In  the  rapidly  grow¬ 
ing  forms  the  cells  are  often  granular,  and 
are  evidently  undergoing  fatty  degene¬ 
ration.  The  matrix  is  either  hyaline, 
coarsely  granular,  or  fibrillated,  and  usu¬ 
ally  contains  some  calcareous  or  ossific 
deposits.  The  process  of  ossification  is 
rarel}^  complete,  stopping  short  as  a  rule 
before  the  formation  of  true  bon}'-  tissue. 
The  matrix  is  often  traversed  by  fibrous  bands,  which  sometimes  pro¬ 
duce  a  retiform  appearance.  In  the  larger  and  more  rapidl}'-  growing 
tumors,  these  bands  are  of  considerable  size,  and  convey  vessels,  some¬ 
times  giving  rise  to  much  vascularity.  An  enchondroma  usually  in¬ 
creases  by  endogenous  cell-growth,  but  occasionally  by  invading  the 
surrounding  structures  in  contact  with  it. 

Locality. — Most  frequently  enchondroma  occurs  in  connection  with 
some  of  the  short  bones,  more  particularly  those  of  the  metacarpus  and 
the  phalanges  of  the  fingers  (Figs.  228,  229),  presenting  hard  rounded 
knobs  in  these  situations,  where,  however,  it  seldom  attains  a  greater 


Fig.  327. 


structure  of  Enchondroma. 


Fig.  228. 


Large  Enchondroma  of  Index  Finger. 


Fig.  229. 


Ordinary  Enchondroma  of  Finger. 


magnitude  than  a  walnut  or  a  pigeon’s  egg.  When  large,  it  is  commonly 
met  with  in  or  upon  the  head  of  the  tibia  or  the  condyles  of  the  femur, 
forming  in  these  situations  rapidly  increasing  growths  of  considerable 
magnitude.  It  may  also  form  in  the  parotid  region,  in  the  muscular 
interspaces  of  the  neck,  thigh,  leg,  and  in  the  testes.  When  connected 
with  the  bones,  enchondroma  may  either  spring  from  the  periosteum, 
gradually  enveloping,  absorbing,  and  eventuall}’-  destroying,  the  osseous 
structures,  though  at  first  not  incorporated  with  them.  This  is  its  usual 
mode  of  origin  when  occurring  in  the  femur  or  tibia;  when  seated  on  the 
short  bones,  especially  on  the  metacarpus  and  phalanges  (Figs.  228,  229), 
it  commonly  springs  from  the  interior  of  the  osseous  structure,  which 
becomes  expanded  and  absorbed,  and  is  involved  in  the  general  mass  of 
the  tumor.  When  occurring  in  cellular  regions  unconnected  with  bone. 


TTJMOKS  OF  THE  EPITHELIAL  TYPE. 


645 


the  enchondroma  is  softer,  and  does  not  present  such  distinct  cartilage- 
cells  as  the  osseous  enchondroma.  Most  frequently  these  enchondro- 
matous  masses  occur  in  childhood,  or  shortly  after  puberty,  appearing 
to  arise  from  an  overgrowth  of  the  cartilaginous  element  of  the  osseous 
S3^stem  at  this  period  of  life. 

The  Treatment  consists  either  in  excision  of  the  tumor,  or  in  ampu¬ 
tation  of  the  affected  part.  Excision  may  be  practised  when  the  tumor 
is  seated  in  the  parotid  region,  or  otherwise  unconnected  with  bone. 
When  forming  part  of  the  osseous  structures  it  cannot  well  be  got  rid  of 
without  the  removal  by  amputation  of  the  bone  that  it  implicates.  When 
it  occurs  in  the  hand,  removal  of  the  affected  fingers  and  metacarpal 
bones,  to  an  extent  proportioned  to  the  amount  of  the  disease,  will  be 
required.  In  Fig.  19  may  be  seen  the  kind  of  hand  left  after  operation 
in  the  case  from  which  Fig.  229  was  taken.  If  in  these  circumstances 
excision  of  the  tumor  only  be  attempted,  it  will  be  found  that  the  whole 
mass  cannot  be  removed,  and  that  it  rapidly  grows  again  ;  or  that  the 
wound  formed  b^’’  the  operation  remains  fistulous  and  open.  Most  com¬ 
monly  a  permanent  cure  is  effected  by  the  ablation  of  the  tumor  in  one 
or  other  of  these  ways ;  but  cases  have  occurred  of  the  more  rapidly 
growing  form  of  the  disease  recurring,  after  its  removal,  in  a  softer  state 
than  before,  and  with  a  close  approximation  to  malignancy^  in  appear¬ 
ance  and  action. 

It  is  worthy  of  remark,  as  showing  the  connection  between  enchon¬ 
droma  and  malignant  disease,  that  cartilaginous  masses  have  been  met 
with  in  the  midst  of  encephaloid  tumors  of  the  bones  and  testes. 

3.  Tumors  derived  from  or  formed  upon  the  type  of  Bone. — 
This  group  includes  three  principal  varieties :  the  Exostoses,  Osteosar¬ 
comata,  and  Malignant  Osteoid.  It  will  prove  more  convenient,  however, 
to  consider  their  anatomical  structure  together  with  their  clinical  cha¬ 
racter  in  the  chapter  devoted  to  the  Diseases  of  Bone. 

lY.— TUMORS  OF  THE  EPITHELIAL  TYPE. 

The  general  features  presented  by  this  tjq^e  of  structure  have  been 
already  explained,  and  it  will  be  found  that  the  tumors  now  to  be  con¬ 
sidered  represent  an  attempt  to  return  to  the  same  standard,  this  result 
being  most  completely  realized  in  the  epithelioma.  The  members  of  this 
group  constitute  the  Cancers^  and  are  not  only  the  most  heterologous  in 
structure,  but  the  most  malignant  in  progress,  of  the  whole  series  of 
new  formations  now  under  consideration. 

Cancer. — Before  proceeding  to  the  individual  growths  forming  this 
class,  it  will  be  desirable  to  say  a  few  words  upon  the  subject  of  cancer 
generall}^^  The  term  has  been  very  vaguely  applied,  the  older  patholo¬ 
gists  placing  under  this  head  all  growths  which  presented  a  malignant 
aspect,  intense  rapiditj'  of  growth,  or  recurrence  after  operation;  thus 
several  of  the  tumors  already  described  have  been  considered  to  be 

1  It  is  not  my  intention  to  enter  largely  into  the  general  history  of  malignant 
diseases,  as  space  will  not  admit  of  my  doing  so;  I  would  therefore  refer  my  readers, 
who  wish  for  further  information  on  this  interesting  subject,  to  the  works  of  Aber- 
nethy ;  the  papers  by  Lawrence ;  the  admirable  and  magnificent  Illustrations  of  the 
Elementary  Forms  of  Disease^  by  Sir  R.  Carswell;  to  the  excellent  and  copious 
monograph  by  Walshe;  and  to  Paget’s  philosophic  Lectures  on  this  subject. 
Amongst  the  foreign  works  may  be  mentioned  Traite.des  Tumeurs  by  Broca  ;  and 
Billroth’s  Handbook  of  General  and  Special  Surgery^  and  General  Surgical  Patho¬ 
logy  and  Therapeutics. 


646 


TUMORS. 


cancers.  The  occasional  coexistence  of  true  cancer  with  cartilaginous, 
bon}",  or  erectile  tissue,  has  given  rise  to  special  varieties  called  respect¬ 
ively  Chondroid,  Osteoid,  and  Aneurismal.  Accidents  of  structure  or 
appearance  have  been  designated  b}"  special  names,  as  Cystic,  Villous, 
Fungoid,  Melanotic,  etc.,  and  thus  much  confusion  has  resulted. 

Cancers  maybe  convenient!}"  divided  into  three  groups,  which  must  not, 
however,  be  taken  as  possessing  any  positively  distinctive  characters, 
but  merely  as  types  of  certain  important  varieties,  viz. :  Encephaloid, 
soft  or  acute  Cancer;  Scirrhus,  hard  or  chronic  Cancer;  and  Epithelial  or 
integumental  Cancer.  This  division  will  be  found  to  facilitate  the  study 
of  the  numerous  minor  varieties  which  occasionally  present  themselves. 

Viewing  the  three  varieties  of  cancer  above  enumerated  as  formed 
upon  a  common  type,  we  cannot  be  surprised  at  finding  very  numerous 
points  of  resemblance  existing  amongst  them  ;  thus  one  form  of  cancer 
may  take  the  place  of  another,  or  be  associated  with  it ;  encephaloid  oc¬ 
curring  after  the  removal  of  scirrhus,  or  being  associated  with  a  struc¬ 
ture  allied  to  epithelioma.  This  identity  of  seat  and  of  recurrence, 
which  tends  more  than  anything  else  to  establish  a  common  origin 
amongst  these  tumors,  has  been  specially  pointed  out  by  Carswell. 
Then,  again,  these  tumors  are  all  of  a  truly  malignant  character,  having 
a  tendency  to  indtice  a  peculiar  and  similar  condition  of  system  that 
goes  by  the  name  of  the  Cancerous  Cachexy.  In  chemical  composition, 
also,  they  are  nearly  identical,  being  principally  composed  of  albumen. 

We  will  now  describe  and  compare  the  Scirrhus  and  Encejjhaloid  can¬ 
cers:  the  epithelial  form,  presenting  some  very  marked  peculiarities  of 
structure,  will  be  more  conveniently  considered  apart  from  the  others. 

Microscopic  Structure. — The  microscopic  characters  of  the  different 
forms  of  cancer  have  of  late  years  attracted  considerable  attention 
amongst  pathologists.  They  consist,  in  all  the  varieties,  essentially  of 
the  same  elements,  though  these  may  differ  somewhat  in  appearance, 
and  in  relative  preponderance,  in  the  difierent  forms  of  the  affection. 

A  cancer  always  presents  a  heterogeneous  commingling  of  cells  and 
fibres  with  an  intercellular  substance  in  the  form  of  a  suspending  fluid. 


Fig.  230. 


Scirrhus  of  Breast :  showing 
Cells  and  Fibres. 


Fig.  231. 


Scraping  from  Scirrhus  of  Breast. 


which  varies  much  in  quantity,  being  scarcely  recognizable  in  the  epithe¬ 
lial  varieties.  The  cells  are  always  grouped  irregularly,  and  lie  in  close 
contact  with  one  another  (Fig.  230).  It  is  much  disputed,  whether  there 
is  any  fibrous  stroma  properly  belonging  to  the  cancer,  and  whether  the 
fibrous  structures  always  present  to  a  greater  or  less  extent  in  these 
growths  really  only  represent  the  remnants  of  the  pre-existing  tissues 


MICROSCOPIC  STRUCTURE  OF  CANCER. 


647 


invaded  by  the  tumor.  Certainly  the  tendency  of  the  formation  is  to 
revert  to  a  type,  the  distinctive  feature  of  which  is  the  absence  of  inter¬ 
cellular  substance.  These  tumors  3deld  b^”  scraping  or  pressure  a  turbid 
fluid,  termed  the  Cancer-juice^  in  which  granules,  cells,  pigmentaiy  and 
fatty  matters,  are  found  in  vaiying  proportions  (Fig.  231).  The 
granules^  w’hich  are  minute,  sometimes  amorphous,  at  others  presenting 
that  peculiar  vibratory  condition  termed  the  molecular  movement,  are 
met  with  in  all  the  varieties  of  cancer,  though  the}"  occur  in  largest 
quantity  in  scirrhus.  Some  pathologists  attach  more  importance  to  the 
character  of  the  stroma  than  to  the  cells  or  the  cancer-juice.  Thus, 
Cornil  and  Ranvier  deflne  cancer  as  a  tumor  composed  of  a  fibrous 
stroma,  bounding  alveoli,  which  form  by  their  communication  a  cavern¬ 
ous  system.  It  is  in  these  alveoli  that  the  cells  lie  free  in  the  cancer- 
juice.  The  milky  juice,  it  must  be  observed,  is  not  absolutely  charac¬ 
teristic  of  cancer.  It  is  yielded  by  the  lymphadenomata  and  by  all  the 
sarcomata,  provided  at  least  twenty-four  hours  elapse  after  their 
removal  before  they  are  examined.  By  other  pathologists,  the  cells 
have  been  looked  upon  as  characteristic  of  the  disease,  though  errone¬ 
ously  so  in  the  strict  acceptation  of  the  term  ;  they  present  characters 
which  are  so  far  distinctive,  that,  when  they  are  viewed  in  connection 
with  the  other  elements  of  the  growth,  it  is  not  difficult  to  determine 
the  true  nature  of  the  formation.  It  must,  however,  be  remembered 
that  no  decided  opinion  can  be  formed  concerning  the  character  of  any 
growth  from  the  examination  of  a  few  isolated  cells ;  'the  general 
arrangement  of  the  elements,  and  the  mode  in  which  the  tumor  invades 
the  surrounding  tissues,  constituting  far  more  important  aids  in  deter¬ 
mining  this  point.  Cancer-cells  are  usually  large,  spherical,  fusiform, 
spindle-shaped,  diptychal  or  caudate,  with  one  or  more  large  nuclei 
placed  eccentrically,  each  containing  a  prominent  nucleolus,  which 
however  does  not  as  a  rule  present  that  glistening  highly  refractive 
appearance  commonly  seen  in  the  fibro-plastic  growths.  In  encephaloid 
the  cells  present  a  very  great  variety  of  size  and  form;  they  are  most  com¬ 
monly  round,  oval  or  slightly  caudate,  vaiying  from  ^5^00^^^  4oVotF 
of  an  inch  in  diameter,  and  they  contain  usually  a  single  large  ovoid 
nucleus  and  a  distinct  punctiform  nucleolus  (Fig.  232).  These  cells 
rapidly  undergo  fatty  degeneration,  and  appear  like  minute,  dark,  finely 
granular  balls,  which  break  down  very  rapidly.  The  cell-wall  is  readily 
affected  by  dilute  acetic  acid  or  potash,  the  nucleus  being  rendered  more 
distinct  by  these  reagents.  The  cells  of  scirrhus  are  larger,  varying 
from  7  Jo^h  to  diam¬ 

eter,  more  irregular  in  outline,  often 
appearing  shrivelled  or  withered;  they 
frequently  present  two  or  more  nuclei 
which  are  large,  prominent,  oval,  and 
nucleolated  (Figs.  231,  233).  The  cell- 
contents  are  granular  ;  and  the  cells  are 
frequently  found  undergoing  fatty  degene¬ 
ration,  as  in  the  encephaloid  forms.  A 
large  amount  of  granular  debris  and 
molecular  matter  is  to  be  seen  amongst 
the  cells.  The  relation  of  th^  growths 
to  the  surrounding  structures  can  only 
be  studied  by  examining  sections,  taken 
after  the  mass  has  been  hardened  in  a 
solution  of  chromic  acid  (two  per  cent.) 


Fig.  232. 


Cells  from  Encephaloid  of  Tongue  (rapidly 
recurring).  Magnified  300  diameters. 


648 


TUMOKS. 


(Fig.  234).  A  cancer  will  then  be  found  to  invade  the  neighboring  parts 
in  such  a  manner,  that  no  satisfactory  line  of  demarcation  can  be  drawn 
between  it  and  the  normal  structures. 


Fig.  233. 


Cells  from  Scirrlias  of  Breast  (rapidly  recur¬ 
ring).  Magnified  300  diameters. 


Fig.  234. 


Scirrlius  of  Breast,  hardened  in  Chro¬ 
mic  Acid  :  showing  Stroma. 


Much  diversity  of  opinion  exists  amongst  Surgeons  as  to  the  value 
that  should  be  attached  to  these  microscopic  signs  in  determining 
the  true  nature  of  many  tumors  ;  some  being  guided  by  these  appear¬ 
ances  alone,  others  looking  upon  them  as  uncertain  and  fallacious,  and 
trusting  rather  to  the  general  character  of  the  growth.  The  latter, 
however,  appears  to  me  to  be  too  limited  a  view  of  the  subject ;  for, 
although  the  unaided  eye  of  an  inexperienced  Surgeon  may  in  many 
cases  recognize  the  true  character  of  a  tumor,  and  the  microscope  in 
some  few  instances  fail  to  afford  much  additional  information,  yet  there 
can  be  no  doubt  tliat  in  most  cases  it  is  only  by  the  aid  of  this  instru¬ 
ment  that  the  real  nature  of  the  growth  can  he  absolutel}'  determined. 

It  is  doubtless  true  that  every  one  of  the  microscopic  elements  above 
described  may  separatel}’  occur  in  the  normal  tissues  and  secretions  of 
the  bod3',  some  in  the  adult,  others,  as  the  caudate  and  fusiform  cor¬ 
puscles,  in  the  embryo :  but,  though  this  be  the  case,  it  does  not 
appear  that  thej"  are  ever  found  similarly’-  grouped  in  any  tumors,  exce^Dt 
those  of  a  cancerous  nature ;  and  in  these  it  is  rather  b}’’  the  aggre¬ 
gation  of  these  appearances,  than  by  an}^  single  one  in  particular,  that 
the  true  character  of  the  disease  is  determined.  In  his  examinations, 
however,  the  experienced  Surgeon  will  find  that  the  appearances  pre¬ 
sented  to  the  naked  eye  will  assist  him  much  in  pronouncing  upon  the 
malignant  or  cancerous  character  of  the  tumor.  It  is  certainl}’-  a 
remarkable  circumstance,  that  the  “recurring”  or  semi-malignant 
diseases,  as  well  as  those  that  are  truly  cancerous  or  j^ositivel^^  malig¬ 
nant,  present  under  the  microscope  structures  that  closely  resemble 
those  of*  tissues  in  process  of  development,  either  in  the  form  of  imper¬ 
fect  exudation-matter  and  fibro-areolar  tissue,  as  in  the  fibro-plastic 
tumors,  or  of  the  corpuscles  of  encephaloid,  which  resemble  some  of 
those  of  the  soft  tissues  in  the  embiyo. 

Progress. — The  general  characters  that  attend  the  progress  of  the 
scirrhous  and  encephaloid  forms  of  cancer  present  numerous  points  of 
resemblance.  When  once  formed,  the  tumor  continues  progressive!}’  to 
increase  in  size,  with  a  degree  of  raj^idit}’,  and  to  an  extent  that  vary 
according  to  its  kind ;  the  scirrhous  tumor  growing  most  slowly,  and 
attaining  but  moderate  dimensions;  the  encephaloid  often  with  great 


SCIRRHUS. 


649 


rapidity,  and  to  an  immense  size.  When  the  full  growth  of  the  tumor 
has  been  attained,  the  process  of  decay  commences.  The  mass  softens 
at  some  point,  the  skin  covering  which  becomes  duskily  inflamed  and 
ulcerated,  and  an  irregular  sloughy  aperture  forms,  through  which  the 
debris  of  the  mass  are  eliminated  in  an  ichorous  or  sanious  fluid,  having 
often  a  peculiar  fetid  smell.  The  ulcer  then  rapidly  increases,  with 
everted  edges,  a  hard  and  knobby,  or  soft  and  fungating  surface,  and  the 
discharge  of  a  dark  fluid,  often  attended  by  hemorrhage,  and  occasionally 
with  sloughing  of  portions  of  the  mass.  Coincidently  with  the  implica¬ 
tion  and  ulceration  of  the  skin,  there  is  usually  deposit  in  the  lymphatic 
glands  with  great  increase  of  pain,  and  most  commonl}''  with  the  super¬ 
vention  of  the  constitutional  cachexy;  though  in  some  cases  this  condi¬ 
tion  precedes  the  cutaneous  implication.  This  cachexy  appears  to  be  the 
result  of  the  admixture  of  cancer-germs  with  the  blood,  and  their  circu¬ 
lation  through  the  body ;  or  of  some  other  modification  in  the  condition 
of  the  blood,  induced  b}"  the  action  of  the  morbid  growth  on  the  econoni}". 
The  exhaustion  resulting  from  the  ulceration,  sloughing,  and  consecu¬ 
tive  hemorrhage,  also  coinmonl}’’  increases  this  cachectic  state;  in  many 
instances  it  is  not  marked  until  after  the  skin  has  become  affected,  and 
in  others  it  does  not  supervene  until  ulceration  is  actually  set  up.  In 
this  cachexy  the  countenance  is  peculiarl}'  pale,  drawn,  and  sallow,  so 
that  the  patient  has  a  very  anxious  and  care-worn  look.  The  general 
surface  of  the  body  acquires  an  earthj^  or  3'ellowish  tint,  and  not  unfre- 
quently  large  spots  of  pityriasis  or  chloasma  make  their  appearance  on 
various  parts  of  it;  the  appetite  is  imi')aired,  the  voice  enfeebled,  the 
muscular  strength  greatl}'' diminished,  and  the  pulse  weak.  The  patient 
complains  of  pains  in  the  limbs,  of  lassitude,  and  of  inability  for  exer¬ 
tion;  he  amaciates  rapidly",  and  frequently  suffers  by  the  occurrence  of 
cancerous  deposits  in  internal  organs ;  and  at  last  dies  from  exhaus¬ 
tion.  induced  by  the  conjoined  effects  of  weakening  discharges,  general 
debility',  and  pain. 

These  general  characters  of  cancerous  growths  present  certain  varie¬ 
ties  of  importance,  according  to  the  form  of  the  disease  that  is  developed. 

Seirrhus. — The  scirrhus,  or  hard  cancer,  is  most  commonly  met  with 
as  a  primary  deposit  in  the  female  breast,  in  various  portions  of  the 
alimentary  canal,  as  the  (esophagus,  the  pylorus,  the  sigmoid  flexure  of 
the  colon,  and  the  rectum,  in  the  tongue,  the  penis,  and  the  skin  ;  secon¬ 
darily,  in  the  l3"mphatic  glands.  It  occurs  in  two  forms  ;  either  as  a 
circumscribed  mass,  or  infiltrated  in  the  tissue  of  an  organ.  In  either 
case  it  forms  a  hard,  craggy  incompressible,  and  nodulated  tumor,  at 
first  movable  and  unconnected  with  the  skin,  but  soon  acquiring  deep- 
seated  attachments,  and  implicating  the  integument.  It  grows  slowly, 
seldom  attaining  a  larger  size  than  an  orange.  At  times  painless,  at 
others  it  is  painful,  aching  generally,  occasionally  with  much  radiating 
and  shooting  pain  through  it.  These  sensations  vaiy  according  to  the 
part  affected,  and  to  the  sensibility  of  the  individual ;  the  pains  are  espe¬ 
cially  severe  after  the  tumor  has  been  handled,  and  at  night  are  of  a 
lancinating,  neuralgic  character.  The  tumor  may  thus  continue  in  a 
chronic  state  for  a  considerable  length  of  time,  slowly  increasing, 
gradually  extending  its  deeper  prolongations,  and  implicating  the  more 
superficial  parts.  In  some  cases,  more  particularly  in  elderly  people, 
scirrhus  gives  rise  to  atrophy  of  the  organ  in  which  it  is  seated,  causing 
wrinkling  and  puckering  of  the  surrounding  skin,  which  becomes  adhe¬ 
rent  to  the  tumor;  and  the  cancer  may  thus  continue  in  a  very  chronic 
state. 


650 


TUMORS. 


The  ucleration  usually  takes  place  by  the  skin  becoming  adherent  at 
one  point  to  the  tumor,  either  b}’  dimpling  in,  being  as  it  were  drawn 
down  towards  it,  or  else  b}^  being  pushed  forwards,  stretched,  and  impli¬ 
cated  in  one  of  its  more  prominent  masses  ;  it  then  becomes  of  a  dusky 
and  livid  red,  somewhat  glazed,  and  covered  by  a  fine  vascular  network. 
Softening  occurs  at  one  point,  where  a  crack  or  fissure  forms ;  a  clear 
drop  of  gumm}"  fluid  exudes  from  this,  and  dries  in  a  small  scab  upon  the 
surface ;  this  is  followed  bj^  a  somewhat  blood}^  discharge  of  a  thick  and 
glutinous  character;  and  the  small  patch  of  skin  from  which  it  issues, 
becoming  undermined,  speedily  sloughs  awa3",  leaving  a  circular  ulcer. 
This  gradually  enlarges,  becoming  ragged  and  sloughy,  with  craggy 
everted  edges,  having  irregular  masses  arising  from  its  surface,  and  dis¬ 
charging  a  fetid  sanious  pus.  The  pain  increases  greatly;  and,  the 
l3^m))hatic  glands  becoming  involved,  the  cachexy  is  fully  developed, 
and  the  patient  is  destroyed  by  it  or  by  the  secondary  visceral  deposits. 
In  old  people,  ulceration  of  scirrhous  masses  often  assumes  an  extremely 
chronic  character,  the  growth  in  them  not  being  endued  with  the  same 
vitality  as  in  the  3"oung.  The  ulcer  in  these  cases  is  flat,  slough}’’,  of  a 
grayish-green  color,  hard  and  rugged,  with  puckered  edges,  and  much 
wrinkling  of  the  surrounding  skin,  and  exhaling  the  usual  fetid  odor. 
In  younger  persons,  and  especially  in  stout  women  with  florid  com¬ 
plexions,  the  disease  usually  makes  rapid  progress.  So  also,  if  inflam¬ 
mation  be  accidentally  set  up  in  the  neighboring  tissues,  cancerous 
infiltration  takes  place  in  them,  in  consequence  probably  of  the  products 
of  inflammation  effused  around  the  tumor  undergoing  cancerous  trans¬ 
formation  almost  as  soon  as  deposited.  I  once  had  under  my  care  an 
old  man  with  a  cancerous  tumor  of  the  leg,  which  after  remaining  sta¬ 
tionary  for  seven  years,  became  accidentally  inflamed,  and  afterwards 
increased  with  great  rapidity.  Occasionally,  but  very  rarely,  scir¬ 
rhous  masses  slough  out,  leaving  a  large  ragged  cavity,  which  may 
even  cicatrize ;  and  thus  a  spontaneous  cure  has  been  known  to  occur. 
The  cancerous  infiltration  will  extend  to  a  considerable  distance  around 
the  tumor  into  integument  which  to  the  naked  eye  appears  quite  healthy, 
but  with  the  microscope  will  afford  unequivocal  evidence  of  the  existence 
of  cancer-germs  diffused  through  it:  it  extends  like  a  halo  around  the 
original  tumor,  and  very  probably  shades  ofl"  into  the  surrounding 
textures.  It  is  of  great  importance  in  determining  the  question  of 
operation  to  bear  this  in  mind,  and  not  to  act  on  the  supposition  of  the 
tumor  being  abruptly  defined. 

The  secondary  deposits  from  scirrhous  tumors  may  take  place  in  the 
viscera,  more  particularly  the  lungs  or  liver,  or  in  the  lymphatic  glands; 
in  the  former  situation  they  are  often  encephaloid,  in  the  latter  they 
assume  the  scirrhous  form. 

Structure, — After  a  scirrhous  tumor  has  been  removed,  though  still 
feeling  firm  under  the  fingers,  it  is  not  so  hard  as  when  it  was  in  the 
body?  owing,  as  TTalshe  observes,  to  the  escape  of  its  fluids  and  conse¬ 
quent  loss  of  turgescence.  On  cutting  it  with  the  scalpel,  it  usually  creaks 
somewhat  as  it  is  divided,  and  presents  a  whitish  or  bluish-white  glis¬ 
tening  surface,  intersected  by  white  bands,  which  apparently  consist 
partly  of  the  new  structure,  partly  of  included  areolar  tissue.  This 
section  has  not  inaptly  been  compared  to  the  appearance  presented  by  a 
cut  through  a  turnip  or  an  unripe  pear,  hence  termed  napiform  and 
apinoid  by  Walshe;  and,  from  its  reticulated  character,  carcinoma  reti- 
culare  by  Muller.  On  examining  the  fibrous  stroma  or  network  which 
forms  the  basis  of  the  tumor,  it  will  be  found  to  be  composed  of  fibrous 


ENCEPHALOID  CANCER. 


651 


or  fibro-cellular  tissue.  The  soft  grayish-blue  granular  material  seated 
in  the  meshes  of  this,  may'  be  squeezed  or  scraped  off  in  a  liquid  state 
as  cancer-juice.  This  is  composed  of  a  multitude  of  nucleated  corpus¬ 
cles,  granules,  granular  cells,  and  globular,  caudate,  or  spindle-shaped 
bodies. 

Encephaloid. — The  encephaloid  or  soft  cancer,  or,  as  it  is  often 
termed.  Medullary  Sarcoma^  is  the  most  malignant  and  rapidly’  growing 
form  of  this  disease.  It  is  met  with  in  the  globe  of  the  ey^e,  in  the  nares 
and  other  cavities  of  the  face,  in  the  articular  ends  of  bones,  in  the 
testes,  and  the  breast,  and  often  attains  an  enormous  size,  equal  to  that 
of  an  adult  head.  It  occurs  in  two  stages  ;  either  as  a  tumor,  ency’^sted 
or  infiltrated,  or  as  a  fungus  after  protrusion  through  the  skin. 

It  commences  as  a  tumor,  which,  though  occasionally  somewhat  hard, 
is  usually  from  the  first,  or  at  all  events  soon  becomes,  soft  and  elastic, 
being  more  or  less  lobulated,  growing  rapidly^,  and  having  an  elastic  and 
at  last  a  semi-fluctuating  feel.  The  skin  covering  it  is  usually  at  first 
pale  and  loose,  with  a  large  network  of  dilated  veins  spreading  over  it. 
In  some  cases,  however,  at  a  veiy  early  period,  a  species  of  inflammatory 
oedema  occurs  in  the  integuments  covering  rapidly’  growing  encephaloid 
tumors.  As  the  tumor  enlarges,  the  skin  becomes  adherent,  discolored, 
of  a  purple-brown  tint,  and  at  last  ulcerates  at  one  point.  When  once 
the  tumor  has  made  its  way  through,  and  is  relieved  from  the  pressure 
of  the  fascia  and  integuments,  the  rapidity  of  its  growth  becomes  fear¬ 
fully’  increased;  and  a  large  soft  fungous  mass,  rugged,  irregular,  dark- 
colored,  and  bleeding  profusely’,  rapidly’  sprouts  forth,  constituting  the 
affection  to  which  Hey  gave  the  appropriate  term  of  fungus  haematodes  : 
when  this  condition  has  been  reached,  death  rapidly’  ensues  from  exhaus¬ 
tion  and  hemorrhage.  Pulsation  has  been  met  with  in  particular  forms 
of  veiy  vascular  encephaloid  ;  in  these  cases  also  a  loud  bruit  synchro¬ 
nous  with  the  pulsation  and  the  heart’s  action  has  been  detected,  and 
may  be  heard  on  the  application  of  a  stethoscope.  These  symptoms 
have  been  most  frequently’  met  with  in  encephaloid  tumors  connected 
with  bone,  and  may’,  unless  care  be  taken,  cause  the  disease  to  be  con¬ 
founded  with  aneurism. 

The  constitutional  cachexy  in  encephaloid  occurs  early,  and  is  well 
marked ;  and  secondary  affections  of  the  lymphatic  glands  and  viscera, 
occasionally  of  a  scirrhous  character,  often  take  place. 

Structure. — After  removal,  the  tumor  is  found  to  be  veiy  vascular, 
displaying  on  injection  a  close  network  of  vessels.  On  a  section  being 
made,  it  commonly’’  presents  a  soft  pnlpy  white  mass,  closely’  resembling 
cerebral  substance,  stained  and  blotched  with  bloody^  patches,  varying  in 
color  from  a  bright  red  to  a  maroon-brown,  this  being  dependent  on 
blood  that  has  been  infiltrated  into  its  substance.  In  other  cases  its 
section  has  been  compared  to  that  of  a  raw  potato,  or  a  piece  of  boiled 
ndder.  On  close  examination,  its  tissue  will  be  found  to  consist  of  a 
stroma  of  delicate  fibres  supporting  the  soft  medullary’  or  brain-like 
structure ;  this  is  composed  in  a  great  measure  of  large  quantities  of 
corpuscles,  nucleated,  compound,  and  granular,  fusiform,  angular, 
clubbed,  or  caudate,  often  with  two  terminations. 

Other  varieties  of  Cancer. — Special  names  have  been  given  to 
varieties  of  cancer,  dependent  merely’  on  peculiarities  of  appearance  or 
structure.  Two  only  of  these,  the  Colloid  and  the  Melanotic^  require 
notice  in  this  place. 

Colloid.,  Gelatinous^  or  Alveolar  Cancer  may^  occur  in  distinct  masses, 
often  of  a  very  large  size,  weighing  many^  pounds,  or  may  be  infiltrated 


6o2 


TUMOES. 


into  the  tissue  of  organs.  As  it  is  most  commonlj^  met  with  in  the  vis¬ 
cera  of  the  abdomen,  it  does  not  so  often  fall  under  the  observation  of 
the  Surgeon  as  the  other  varieties  of  cancer.  Yet  it  may  form  super¬ 
ficially.  I  have  met  with  it  in  the  breast,  forming  a  very  large  tumor ; 
and  there  is  a  preparation  in  the  Universit}^  College  Museum  of  a  scir¬ 
rhous  breast  containing  colloid.  It  consists  of  cells  filled  with  a  clear 
semi-transparent  3"ellowish  gelatinous  or  honey-like  material,  resembling 
indeed  exactl^^  the  structure  of  a  honeycomb.  The  septa  forming  these 
cells  are  distinctly"  fibrous,  and  regular  in  their  arrangement.  The 
gelatinous  matter  contains  caudate  and  nucleated  cells  in  considerable 
quantity",  presenting  the  same  characters  as  those  of  the  other  varieties 
of  cancer. 

There  is  a  growing  belief  among  pathologists  that  this  variety’’  merely 
represents,  as  it  w’ere,  an  accident  of  structure,  viz.,  the  gelatinous  con¬ 
dition,  and  that  the  tumors  to  which  the  name  has  been  applied  really" 
belong  to  one  of  the  three  following  classes  : — 

1.  Glandular  Formations  in  which  the  cells  have  undergone  colloid 
change,  as  in  the  so-called  colloid  cancer  of  the  mucous  membrane  of  the 
stomach  and  intestine. 

2.  Fibro-plastic  Tumors,  with  an  unusual  amount  of  gelatinous  inter¬ 
cellular  substance  and  well-marked  fibrous  septa,  containing  elongated 
spindle-shaped  cells,  with  a  few  more  oval  or  caudate.  This  form  is 
chiefly"  found  in  the  intermuscular  fibrous  s'epta  ;  but  I  have  met  with  it 
in  the  mamma. 

3.  True  Cancers,  either  Encephaloid  or  Scirrhus,  in  which  the  cells 
have  undergone  colloid  degeneration. 

Melanosis  or  Black  Cancer  has  been  specially"  studied  by  Sir  Robert 
Carswell,  who  arranged  it  under  the  heads  of  Punctiform  3Ielanosis^  in 
which  the  dark  pigmentary"  matter  occurs  in  the  shape  of  minute  points 
or  dots  scattered  over  a  considerable  extent  of  surface  ;  Tuheriforin 
Melanosis^  occurring  in  tumors  which  vaiy  in  bulk  from  a  millet-seed  to 
an  egg  or  an  orange,  alwavs  assuming  a  globular,  ovoid,  or  lobulated 
shape,  and  being  principally^  met  with  in  the  areolo-adipose  tissue,  or  on 
the  surface  of  serous  membranes  ;  and  Stratiform  and  Liqiiiform  Me¬ 
lanosis^  which  takes  place  principally"  upon  serous  membranes,  or  in 
accidental  cavities,  where  the  black  pigmentary-  matter  looks  not  unlike 
Indian  ink.  Melanosis  most  frequently"  presents  itself  to  the  Surgeon 
in  connection  with  the  ey-e,  occasionally-  in  the  skin  and  subcutaneous 
areolar  tissue,  and  rarely-  in  the  bones.  It  closely-  resembles  in  its 
general  progress  and  characters  the  encephaloid  form  of  cancer,  ulce¬ 
rating  and  throwing  out  dark  fungous  masses,  and  afiecting  like  it 
internal  organs,  more  particularly-  the  eye  and  the  lungs.  Paget,  indeed, 
regards  melanosis  as  being,  with  very- rare  exceptions,  merely- medullaiy 
or  encephaloid  cancer  modified  by-  the  deposition  of  black  pigment. 
Occasionally",  as  Carswell  has  pointed  out,  it  is  distinctly-  associated 
with' the  other  varieties  of  this  disease.  In  microscopic  structure  it 
resembles  encephaloid,  consisting  of  a  stroma,  with  caudate,  granular, 
and  compound  cells,  but  containing  a  large  quantity  of  pigmentaiy 
matter  in  granules,  molecules,  and  masses. 

Diagnosis. — The  diagnosis  of  the  different  forms  of  cancer  is  not 
alway's  easily-  made.  Scirrhus,  when  in  tumor,  may  very  readily  be 
confounded  with  fibrous  tumors  and  chronic  glandular  masses,  or  with 
the  indurated  atrophy-  of  a  part ;  in  many-  of  these  cases,  indeed,  the 
diagnosis  cannot  be  correctly^  effected  until  after  removal.  In  other 
cases,  however,  the  rugged  feel,  the  lancinating  pains,  and  the  tendency 


CAUSES  OF  CANCER. 


653 


to  the  implication  of  the  lymphatics,  or  to  affecting  the  general  health, 
will  commonly  serve  to  establish  the  diagnosis.  AVhen  ulceration  has 
taken  place,  the  previous  condition  of  the  tumor,  the  general  character 
of  the  sore,  and  the  microscopic  examination  of  the  debris,  may  serve 
to  establish  its  true  character. 

Encephaloid  in  tumor  ma3^be  confounded  with  abscess,  with  cysts,  or 
with  fatt}',  erectile,  and  sanguineous  tumors  ;  and,  when  pulsating,  with 
aneurism.  In  these  cases  careful  palpation,  the  existence  of  elasticity 
without  fluctuation,  and  the  presence  of  the  large  and  tortuous  veins 
ramifj’ing  over  the  surface  of  the  mass,  may  establish  its  true  character. 
When  it  is  fungating,  it  might  be  confounded  with  the  sprouting  intra- 
cystic  growths  that  sometimes  spring  from  the  interior  of  a  C3'stic 
tumor.  Here,  however,  a  microscopic  examination  of  the  debris,  as  well 
as  the  existence  or  absence  of  contamination  of  neighboring  l^^mphatics, 
will  establish  the  true  nature  of  the  affection. 

The  diagnosis  of  a  tumor  as  a  cancer  is  sometimes  materially  obscured 
by  the  accidental  development  of  abscess  in  the  tissues  around  or  above 
it.  In  such  cases,  the  continuance  of  a  swelling  which  is  evidently  not 
inflammatoiy,  after  the  pus  has  been  evacuated,  may  lead  to  a  suspicion 
as  to  the  true  nature  of  the  disease. 

Causes. — The  causes  of  cancer  are  often  exceedingl}’  obscure.  In 
man}'  cases  it  undoubtedly  is  hereditary.  Xothing  is  more  common  than 
to  And  that  the  grandmothers,  mothers,  or  aunts  of  patients  affected  by 
cancer,  have  died  of  the  same  disease.  Telpeau  says  that  it  was  so  in 
more  than  one-third  of  the  patients  he  met  with  ;  not  that  the  disease 
itself  is  existent  at  birth,  but  that  the  tendency  to  it  is  connate ;  that 
tendency  manifesting  itself  at  those  periods  of  life  and  in  those  organs 
in  which  cancer  usually  develops  itself.  It  may,  however,  actually 
be  a  congenital  affection ;  thus  it  has  been  met  wdth  in  the  eye  at  birth, 
and  in  the  Museum  of  University  College  is  a  preparation  of  a  small 
melanotic  tumor  existing  in  the  cerebellum  of  a  child  that  only  lived 
three  days  after  birth.  It  may  occur  at  all  periods  of  life  from  the 
earliest  ages ;  and  will  evince  itself  in  persons  from  eighty  to  ninety 
years  of  age.  According  to  W^lshe,  the  mortality  from  cancer  goes 
on  steadily  increasing  till  the  eightieth  year ;  hence  the  popular  belief, 
that  the  middle  period  of  life  is  most  obnoxious  to  it,  would  appear  to 
be  an  erroneous  one.  Age,  however,  influences  the  liability  to  cancer  in 
special  organs.  Thus  cancer  of  the  eye  and  of  the  bones  frequently 
occurs  in  children ;  of  the  testes,  not  uncommonly,  in  young  adults ; 
whilst,  in  the  female,  Sibly  states  that  the  average  age  of  patients  with 
uterine  cancer  is  forty-three,  and  with  mammary,  forty-eight  years.  All 
forms  of  cancer  are  not,  however,  met  with  in  equal  frequency  at  all  ages ; 
the  encephaloid  being  the  most  common  in  the  young  and  scirrhus  in  the 
middle-aged  and  elderly.  The  colloid  variety  rarely  occurs  before  the 
age  of  thirty. 

Depressing  Mental  Emotions,  if  long-continued  or  frequently  repeated, 
may  possibly  predispose  to  the  occurrence  of  cancer.  I  have  seen  so 
many  cases  of  cancer,  more  particularly  of  the  abdominal  organs,  in 
individuals  who  had  suffered  much  from  grief,  anxiety,  or  harass  of 
mind  for  years  before  the  development  of  the  malignant  disease,  that, 
although  the  doctrine  is  incapable  of  proof,  I  cannot  but  look  upon  it  as 
probable,  that  the  cancer  was  the  result  of  the  antecedent  long-continued 
mental  disquietude.  We  know,  by  every-day  experience,  that  functional 
derangement  of  the  abdominal  and  pelvic  organs  of  the  most  inveterate 
character  may  be  occasioned  by  mental  disturbance ;  and  it  appears  to 


654 


TUMORS. 


me  not  improbable,  that  siieh  funetional  derangement  may  at  last  lead  to 
perversion  of  nutrition,  terminating  in  malignant  deposits  in  such  organs, 
as  the  uterus,  the  liver,  or  the  stomach,  as  are  more  readily  influenced  by 
the  condition  of  the  patient’s  mind. 

Cancer  appears  to  occur  with  very  vaiying  degrees  of  frequency  in 
different  parts  of  the  ivorld.  It  is  certainl}’’  more  common  in  Europe 
than  in  any  other  continent.  In  some  parts  of  North  America  and 
China  it  is  also  frequent ;  whilst  in  South  America,  in  Africa  (except 
Egypt),  and  in  the  greater  part  of  Asia,  it  is  not  of  common  occurrence. 
A.  Haviland  has  found  that  in  England  cancer  is  least  common  in  the 
northwestern  and  western  parts  of  the  kingdom,  including  Wales;  and 
that  generally  throughout  the  more  elevated  southern  and  midland  dis¬ 
tricts  it  is  not  common.  This  he  attributes  to  these  parts  lying  on  the 
oldest  geological  formations,  and  being  the  sources  of  rivers  and  the 
best  drained  districts  of  the  country.  On  the  other  hand,  Haviland 
points  out  that  the  sites  of  the  great  cancer-fields  of  England  are  the 
tertiary  formations  and  the  alluvial  districts;  that  cancer  surrounds  the 
course  of  the  great  rivers  after  their  full  formation,  when  they  are  pass¬ 
ing  through  low-lying  valle3'-lands,  liable  to  overflowing  and  the  eonse- 
quent  accumulation  of  deposits.  These  districts  are  also  the  most 
densely  populated ;  and  hence  it  might  be  inferred  that  densit^^  of  popu¬ 
lation  favored  the  production  of  cancer,  and  that,  wherever  social 
organization  was  largely  developed,  there  cancer  was  proportionately 
rife.  But  statistics  do  not  bear  out  this  view.  Thus  we  find  that  the 
mortalit}"  from  cancer  in  Norwich  and  Great  Yarmouth  is  to  that  in 
Liverpool  and  Manchester  as  141  to  84;  and  that  in  Philadelphia  it  is 
to  that  in  New  York  as  15  to  7,  or  fully  twice  as  great;  while  in  Mary- 
lebone  it  is  veiy  far  higher  than  in  the  capital  of  Penns^dvania. 

Is  Cancer  of  Local  or  of  Constitutional  Origin  ?  This  is  a  question 
which  has  been  much  debated  b}^  pathologists  and  Surgeons :  some  hold¬ 
ing  the  opinion  that  the  cancerous  tumor  from  its  first  appearance  is  a 
local  manifestation  of  a  pre-existent  blood-disease;  and  others  believing 
that  the  disease  is  at  first  local,  and  onl}^  becomes  constitutional  by 
secondary  infection  of  the  sj^stem  from  the  local  tumor.  The  answer  to 
the  question  is  of  some  practical  importance,  as  it  has  a  direct  bearing 
on  treatment. 

The  doctrine  of  the  constitutional  origin  of  cancer  may  be  thus  ex¬ 
pressed  in  the  words  of  Paget :  Cancers  are  manifestations  of  certain 
specific  and  morbid  states  of  the  blood ;  and  in  them  are  incorporated 
peculiar  morbid  materials  which  accumulate  in  the  blood,  and  which 
their  growth  ma\"  tend  to  increase.”  “  The  existence  of  the  morbid 
material  in  the  blood,  whether  in  the  rudimental  or  in  the  effective  state, 
constitutes  the  general  predisposition  to  cancer ;  it  is  that  which  is  b^^ 
some  called  the  predisposing  cause  of  cancer.  The  morbid  material  is 
the  essential  constituent  of  the  cancerous  diathesis  or  constitution;  and 
when  its  existence  produces  some  manifest  impairment  of  the  general 
health,  independent!}^  of  the  cancerous  growth,  it  makes  the  primary 
cancerous  cachexia.”  For  the  local  manifestations  of  this  constitutional 
disease,  the  part  where  it  is  developed  must  be  put  into  a  favorable  con¬ 
dition  by  irritation,  injury,  or  other  similar  cause.  The  blood-disease  and 
the  local  conditions  may  compensate  each  other ;  thus,  with  an  intense 
cancerous  diathesis,  tumors  may  be  formed  in  such  a  way  and  in  such 
numbers  as  to  be  apparentl}’"  independent  of  local  condition  ;  while  in 
cases  where  the  constitutional  element  exists  in  a  low  degree,  a  long 
continuance  of  irritation  maybe  required  to  bring  out  its  local  manifes- 


ORIGIN  OF  CANCER. 


655 


tations.  Paget  believes  that  by  this  theory  of  compensation  the  oppos¬ 
ing  views  as  to  the  local  or  constitutional  origin  of  cancer  may  be 
reconciled. 

On  the  other  hand,  it  is  held  that  a  cancerous  tumor  is  often  ah  initio 
local,  occurring  without  any  previous  constitutional  blood-disease  or 
diathesis,  and  becoming  secondarily  constitutional  only  by  absorption 
into  the  sj^stem.  This  opinion,  which  has  been  strongly  supported  by 
Yelpeau  and  Yirchow,  is  founded  on  the  following  reasons.  1.  We  con¬ 
stantly  see  cancerous  tumors  spring  up  in  individuals  who  have  always 
enjoyed  perfect  health,  and  who  are  to  all  appearances  perfectly  well  at 
the  time  of  the  occurrence  of  the  disease.  As  in  these  cases  there  is  no 
evidence  wdiatever  of  constitutional  disease  of  an}-  kind,  it  w’ould  be  a 
begging  of  the  w’hole  question  to  assert  that  the  existence  of  the  local 
affection  must  of  itself  be  taken  as  an  indication  of  a  constitutional  can¬ 
cerous  tendency.  2.  These  tumors  are  not  unfrequentl}^  the  result  of 
some  local  injury  or  irritation.  3.  The  constitutional  health  does  not, 
in  the  majorit}^  of  cases,  suffer  until  some  months  have  elapsed ;  when, 
after  the  lymphatics  or  glands  have  become  implicated,  or  the  neighbor¬ 
ing  tissues  invaded,  but  not  until  then,  signs  of  cachexy  set  in.  4.  If 
the  disease  be  removed  before  neighboring  parts  have  become  contami¬ 
nated,  the  health,  if  it  have  suffered,  often  improves  materiall3\  5.  In 
the  great  majority  of  cases,  the  patient  remains  free  from  any  recurrence 
of  the  disease  for  some  considerable  period.  6.  In  some  instances  no 
recurrence  whatever  takes  place,  the  disease  being  eradicated  from 
the  system,  w’hich  could  not  be  the  case  if  it  w^ere  constitutional. 
7.  When  recurrence  does  take  place  soon  after  an  operation,  it  is  almost 
invariably  either  in  the  cicatrix  or  its  immediate  neighborhood,  owing  to 
cancer-cells  which  had  been  widely  infiltrated  escaping  removal,  and  sub¬ 
sequently  developing  into  a  new  tumor.  Were  the  disease  constitutional, 
recurrence  would  be  as  likel}’  to  take  place  in  other  parts,  or  in  internal 
organs,  as  it  does  when  the  operation  has  been  too  long  dela3'ed.  8.  We 
observe  the  same  tendency  to  recurrence  after  removal,  and  even  to 
secondary  deposit  in  distant  organs,  in  other  tumors  which  are  incon- 
testabl}^  primarily  local,  such  as  the  fibro-plastic  and  the  enchondroma- 
tous,  and  which  only  become  constitutional  in  their  more  advanced 
stages,  and  in  a  secondary  manner. 

Keferring  the  reader  who  is  desirous  of  studjung  the  question  under 
examination  in  its  ph3’siological  and  pathological  aspects,  to  the  writings 
of  Paget,  Moore,  Yirchow^,  Billroth,  and  others,  I  will  here  only  give 
such  a  view  of  our  present  state  of  knowledge  regarding  it  as  may  be 
of  practical  value  to  the  Surgeon. 

Cases  certainl3’’  often  occur,  in  which  cancer  appears  without  an3’  ex¬ 
citing  cause,  being  evidentl3"  the  result  of  some  peculiar  constitutional 
condition,  under  the  influence  of  which  the  local  growth  characterizing 
the  disease  springs  up.  Such  are  cases  in  which  it  is  hereditaiy,  or  in 
w’hich  it  appears  almost  simultaneously  in  different  parts  of  the  bod3^, 
w’ith  a  strongl3^  marked  cachex3\  Y"hat  the  constitutional  condition  in 
these  cases  ma3^  be,  is  doubtful.  Where  a  distinct  cancerous  cachex3"  is 
present,  there  can  be  no  doubt  of  the  existence  of  a  blood-disease  ;  but 
w’hat  has  been  the  antecedent  state  that  has  induced  this  cachexy  where 
no  other  obvious  manifestation  of  the  disease  has  appeared  ?  The 
hereditary  tendency  to  cancer  in  certain  families  is  not  necessarily  a 
proof  of  its  being  a  constitutional  or  blood-disease.  We  see  the  ten¬ 
dency  to  the  hereditary  transmission  of  abnormal  developments  in  such 
cases  as  supernumerar3’’  fingers,  or  exostoses;  but  we  do  not  regard 


656 


TUMORS. 


these  conditions  as  constitutional — dependent  on  some  state  of  the 
blood — merely  because  the  tendency  is  transmitted  from  parent  to  off¬ 
spring.  All  that  we  can  at  present  assume  as  probable  is,  that  in  many 
cases  there  is  a  predisposition  of  unknown  nature,  hereditary  or  other¬ 
wise,  which  may  lead  to  the  development  of  cancer  apparently  without 
the  aetion  of  a  local  excitino-  cause. 

O 

But  cases  frequentl}^  occur  in  which  cancer  can  be  distinctly  traced  to 
some  local  cause,  being  immediately  occasioned  by  a  blow,  injury,  or 
other  violence,  or  by  a  long-continued  irritation  of  the  part  that  event¬ 
ually  becomes  affected.  Thus  a  blow  on  a  woman’s  breast  may  give  rise 
to  cancer ;  and  the  irritation  of  a  broken  tooth  ma}^  occasion  it  in  the 
tongue.  It  is  disputed  whether  external  causes  of  this  kind  can  give 
rise  to  the  production  of  cancer  without  the  previous  existence  of  con¬ 
stitutional  predisposition.  That  cancer,  even  when  apparently  excited 
by  local  causes,  may  in  reality  be  of  constitutional  origin,  cannot  admit 
of  a  doubt ;  more  especially  in  those  cases  in  wliich  it  is  hereditaiy,  or 
in  which  it  makes  its  appearance  almost  simultaneously  in  different  parts 
of  the  body,  with  a  strongly  marked  cachex3^  But  in  many  other 
instances  it  certainl}^  appears  as  if  it  were  strictly  local  in  its  origin,  as 
when  it  slowl^^  occurs  after  the  infliction  of  some  violence,  and  without 
any  evidence  of  constitutional  disturbance  or  contamination.  We  com- 
monl}^  see,  for  instance,  a  woman  in  perfect  health  receive  a  blow  upon 
the  breast,  which  gives  rise  to  some  passing  inconvenience  at  the  time; 
after  a  lapse  of  some  months,  though  still  with  an  unimpaired  state  of 
health,  she  notices  a  small  hard  lump.  This  eventually  proves  to  be  a 
scirrhous  tumor.  It  may  continue  stationaiy,  or  but  slowly  increase  for 
months  or  3’ears,  until  the  turning  point  comes,  at  which  tlie  disease 
begins  to  contaminate  the  skin  or  the  lymphatics,  and  to  be  carried  into 
the  sj^stem,  producing  cachexy"  and  giving  rise  to  a  tendenc}’’  to  the  pro¬ 
duction  of  those  secondaiy  deposits  of  which  we  shall  speak  presently. 
In  such  a  case  as  this,  it  is  impossible  to  look  on  the  cancer  as  of  consti¬ 
tutional  origin — that  is,  as  arising  from  a  manifest  pre-existent  morbid 
condition  of  the  blood.  Still  it  is  difficult  to  understand,  why  an  injuiy 
should  in  one  person  be  followed  by  mere  h3q3er8emia  and  the  consequent 
transitory  disturbance  of  the  nutritive  changes  in  the  part,  while  in 
another  the  same  injuiy  is  followed  by  cancer.  We  know  that  an  exuda¬ 
tion-corpuscle  or  a  pus-cell  is  the  result  of  strictly  local  action ;  and  we 
know  also  that  all  persons  are  liable  to  the  formation  of  these  under 
favorable  conditions.  It  is  true  that  we  are  ignorant  of  the  manner  in 
which  a  cancer-germ  can  be  produced  by  the  local  action  of  the  part  in 
which  it  is  generated,  but  we  are  as  little  acquainted  with  the  essential 
mode  of  production  of  the  exudation-cell  or  pus-corpuscle,  which  we 
know  to  be  the  result  of  strictl3"  local  action ;  and  it  seems  to  me  that 
the  difficulty  is  in  no  way  solved,. but  simply  pushed  back  a  step,  by  the 
attempt  to  prove  that,  in  all  cases  of  cancer-formation,  a  special  condi¬ 
tion  of  the  blood  must  exist,  which  impresses  the  cancerous  character 
upon  local  actions  taking  place  in  the  system.  We  01113"  know  that  it  is 
not  every  one  who  is  liable  to  the  formation  of  cancer ;  and  hence  it  is 
not  very  easy  to  understand  how"  it  should  arise,  unless  there  were  some 
tendency  to  its  formation — some  condition  of  the  bod3"  or  of  the  part 
favoring  the  production  of  those  forms  of  growth  which  constitute  the 
disease.  This  condition  may  be  one  of  such  low  intensity  that,  as  far  as 
regards  the  practical  question  of  the  result  of  removal  of  the  tumor,  we 
may  regard  the  disease  occurring  in  the  circumstances  here  considered 
as  strictl3"  local  in  its  eaii3'  stages,  and  ma3"  expect  that  the  removal  of 


TREATMENT  OF  CANCER. 


657 


the  local  disease  will  be  followed  by  a  more  or  less  prolonged  interval 
during  which  the  patient  shall  remain  in  good  health,  until,  perhaps,  the 
disposition  to  the  formation  of  cancer  shall  have  gained  sufficient  inten¬ 
sity  to  again  manifest  itself,  either  spontaneously  or  as  the  result  of  some 
form  of  irritation. 

Secondary  Dej)Osits  of  Cancer. — A  cancer,  having  been  once  formed, 
may  remain  localized  for  a  longer  or  shorter  time — perhaps  months  or 
3’ears — until  it  begins  to  contaminate  the  skin  or  the  Ij^mphatics,  and 
thus  be  carried  into  the  sj’stem.  It  is  not,  in  cancer  of  the  breast  for 
instance,  until  the  l^miphatics  become  enlarged,  and  the  glands  in  the 
axilla  indurated,  that  the  constitution  begins  to  suffer,  cachexy  sets  in, 
and  a  tendency  to  secondary  deposits  manifests  itself — the  constitu¬ 
tional  cachexy’  developing  as  the  ulceration  and  sloughing  extend,  and 
in  exact  proportion  to  the  progress  of  the  local  affection.  The  internal 
organs  which  are  most  liable  to  become  the  seat  of  secondary  deposits 
are,  first,  the  liver,  and  next  the  lungs.  The  cause  of  these  deposits  is 
somewhat  obscure.  Paget  is  of  opinion  that  in  some  cases,  where  a 
rapid  multiplication  of  cancers  take  place,  this  ma^*  arise  from  an  in¬ 
crease  in  the  cancerous  diathesis  or  morbid  condition  of  the  blood.  But 
he  believes  that  in  most  of  these  cases  there  has  been  a  conversance  of 
cancerous  material  by  the  blood,  in  the  form  of  embola  ;  and  he  supj^orts 
this  view  by  referring  to  the  analogjs  pointed  out  by  Walshe  as  existing 
between  the  secondary  deposits  in  cancer  and  the  secondary  abscesses 
in  pr^aemia ;  the  liver  and  lungs  in  both  cases  being  principally  affected. 
He  refers  also  to  a  case  of  cancer  of  the  liver,  where  the  growths  were 
colored  yellow  b}"  the  bile,  and  in  which  he  found  cancerous  growths  of 
the  same  color  infiltrated  in  the  lungs.  But  he  says  that  it  is  not  neces¬ 
sary  to  suppose  that  entire  cancer-cells  are  thus  transferred ;  cancer- 
juice,  or  minute  fragments  of  cancer-plasma,  ma^^be  as  efficient  as  entire 
cells.  Tirchow  considers  that  the  fact  that  the  secondary  deposit  does 
not  necessarily  occur  in  the  organ  through  which  the  blood  must  first 
pass,  militates  against  the  theory  that  cancer-cells  are  carried  onward 
1)3’  the  circulatiorr,  and  become  impacted  in  the  smaller  vessels  of  the 
part,  in  the  manner  of  embola.  He  inclines  to  the  belief  that  the  can¬ 
cerous  juices  are  absorbed  and  enter  the  circulation  either  directl3’  by 
the  veins  or  indirectl3’'  through  the  13’mphatics,  and  that  they  give  rise 
to  changes  in  the  nutrition  of  certain  parts,  leading  to  the  development 
of  cancerous  growths.  In  whatever  way  w'e  suppose  the  secondary 
deposits  to  be  formed,  we  ma3’  safel3’  assume  that  their  presence  indi¬ 
cates  that  the  S3’stem  is  charged  with  the  material  of  cancer,  and  that 
the  disease  is  no  longer  limited  to  the  spot  in  which  it  first  appeared. 

Treatment  of  Cancer. — The  treatment  of  cancer  ma3’  be  con¬ 
sidered  to  be  constitutional  and  local.  All  Curative  Constitutional 
Treatment  is,  I  believe,  utterl3^  useless,  no  constitutional  remedies  ap¬ 
pearing  to  exercise  an3'  material  influence  on  this  disease.  I  am  not 
acquairrted  with  an3’  case  of  cancer,  either  from  m3’  own  observations, 
from  conversation  with  other  Surgeons,  or  from  published  statements, 
that  affords  satisfactor3^  evidence  of  cure  1)3’  an  internal  remed3’.  It  is 
true  that  man3’  so-called  cases  of  cancer  have,  at  various  times,  been 
stated  to  have  been  cured  by  different  medicines ;  but  it  must  be  borne 
in  mind  that,  in  a  less  advanced  state  of  pathological  knowledge  than 
exists  at  the  present  da3’,  almost  all  hard  chronic  tumors  were  called 
“  scirrhous,’^  and  man3’ intractable  ulcers  “cancers”;  mistakes  which  are 
not  unfrequentl3’  committed,  and  sometimes  unavoidabl3’  so,  even  with 
the  improved  means  of  diagnosis  that  we  at  present  possess,  ^sot  one 
VOL.  I. — 42 


658 


TUMORS. 


of  fhe  many  remedies  that  have  been  vaunted  as  being  specific  in  this 
disease,  and  b}’  which  cures  have  been  stated  to  have  been  effected,  has 
retained  the  confidence  of  the  profession,  or  has,  on  further  trial,  corres¬ 
ponded  in  its  effects  to  the  statements  of  those  who  introduced  it.  I 
therefore  think  it  but  w^aste  of  time  to  discuss  the  supposed  advantage 
to  be  derived  from  hemlock,  sanguinaria,  condurango,  iron,  arsenic, 
iodine,  cod-liver  oil,  or  lemon-juice,  in  the  treatment  of  cancer.  But 
though  curative  treatment  can  effect  nothing  in  these  cases,  much  may 
be  effected  in  cases  that  do  not  admit  of  operation  towards  retarding 
the  progress  of  the  disease  by  proper  Palliative  Treatment.  With  this 
view,  the  diet  should  be  mild,  nutritious,  easy  of  digestion,  unstimu¬ 
lating,  and  suflflcient  to  support  the  strength  under  the  wearing  infiuence 
of  pain  and  discharge;  and  the  preparations  of  opium,  of  conium,  and 
of  hyoscyamus,  must  be  freely  administered  in  order  to  relieve  the 
patient’s  sufferings,  and  to  procure  rest. 

The  Local  Means  are  those  upon  which  the  Surgeon  justly  places  the 
chief  reliance  in  these  affections.  The  Palliative  Local  Treatment  con¬ 
sists  in  the  use  of  means  calculated  to  retard  the  growth  of  the  tumor,  to 
lessen  the  pain  attending  it,  and  to  remove  the  fetor  that  arises  if  it  be 
ulcerated.  In  order  to  prevent  the  rapid  extension  of  the  tumor,  it  is 
of  great  importance  to  subdue  all  local  excitement  within  and  around  it ; 
in  proportion  to  the  amount  of  action  existing  in  the  part,  the  disease 
will  usually  extend  with  rapidity;  any  inflammatory  condition  of  the 
neighboring  tissues  being  especially  prejudicial  in  this  respect.  Hence, 
in  these  circumstances,  the  occasional  application  of  a  few  leeches  will 
often  be  of  considerable  service.  No  counter-irritation,  however,  ought 
to  be  employed  in  the  vicinity  of  the  cancerous  part,  as  it  only  excites 
action  in  and  around  it,  and  hastens  the  process  of  ulceration  ;  the  skin 
especially  is  apt  to  become  rapidly  infiltrated  b}’’  the  cancerous  disease 
under  it,  if  irritated  by  the  application  of  iodine  and  other  stimulants. 
If  the  tumor  be  painful,  and  the  skin  covering  it  still  unbroken,  great 
relief  may  be  obtained  by  the  application  of  belladonna  plasters.  In 
some  cases  I  have  found  powdered  conium,  spread  on  cotton-wadding, 
useful  in  the  same  way.  As  it  is  of  importance  to  prevent,  as  long  as 
possible,  any  breach  of  surface,  the  application  of  these  sedative  pilasters 
and  powders  should  be  persevered  in  with  the  view  of  supporting  the 
integument.  The  local  application  of  ice,  so  as  to  freeze  the  tumor  more 
or  less  completely,  has  been  recommended  by  J.  Arnott ;  it  may,  pos¬ 
sibly,  in  some  cases  retard  the  growth  or  lessen  the  pain,  but  there  is  no 
evidence  to  show  that  it  can  be  considered  as  a  curative  agent.  When 
the  tumor  is  ulcerated,  the  fetor  must  be  diminished  by  the  application 
of  weak  solutions  of  the  chlorides,  of  chloralum,  or  of  Condy’s  disin¬ 
fectant,  to  which  opiates  may  be  advantageously  added  with  a  view  of 
lessening  the  pain. 

The  Curative  Local  Treatment  of  cancer  embraces  three  methods,  viz. : 
destruction  by  caustics ;  absorption  by  pressure  ;  and  removal  by  the 
knife.  All  these  local  means  are  employed  on  one  principle,  viz.,  on  the 
supposition  that  the  cancerous  tumor  which  it  is  proposed  to  destroy,  to 
absorb,  or  to  extirpate,  is  primarily  a  local  disease :  that,  if  this  local 
malady  can  be  removed  sufficiently  early,  constitutional  infection  may 
be  prevented ;  and  that,  even  if  this  have  to  some  extent  taken  place, 
fatal  contamination  of  the  system  may  be  retarded  by  the  removal  of  the 
local  source  of  that  constitutional  infection. 

The  great  objection  that  has  been  urged  against  operating  in  this  dis¬ 
ease  is,  that  cancer  being  assumed  to  be  from  the  first  a  constitutional 


TREATMENT  OF  CANCER  BY  CAUSTICS. 


659 


affection,  it  is  useless  to  remove  the  local  tumor,  leaving  the  constitu¬ 
tional  vice  unrelieved.  If  this  objection  were  tenable,  it  would  apply  to 
the  removal  of  cancers  in  any  way,  and  would  have  as  much  force  against 
removing  cancerous  growth  by  caustic,  by  pressure,  or  by  congelation, 
as  against  extirpating  them  by  the  simpler  and  speedier  means  of  the 
knife,  and  in  fact  must  lead  to  the  conclusion  that  none  but  local  pallia¬ 
tives  are  proper  in  this  disease.  For  such  an  argument  as  this  to  have 
any  value,  it  must  first  be  shown  that  cancer  is  always  ah  origine  a  dis¬ 
ease  depending  on  the  actual  presence  in  the  blood  of  a  certain  morbid 
material,  and  that  it  is  not  in  many  cases  primarily  local,  in  so  far  that 
any  tendenc}^  to  the  formation  of  cancer  has  strictly  limited  its  action  to 
the  part  where  we  find  the  cancer  developed.  The  arguments  which 
have  already  been  adduced,  however,  and  the  results  of  experience,  appear 
to  me  to  be  conclusive  as  to  cancer  being  in  many  cases,  for  all  surgical 
purposes,  primarily  a  local  disease,  and  only  becoming  constitutional 
secondarily  by  contamination  of  the  blood  and  absorption  into  the  sys¬ 
tem,  and  consequently  to  justify  operation  for  the  removal  of  cancerous 
tumors  in  suitable  cases. 

Caustics. — The  employment  of  caustics  for  the  destruction  of  cancers 
has,  in  all  ages  and  countries,  been  resorted  to  by  empirics,  who  profess 
to  remove,  by  secret  remedies  less  painful  and  more  elRcacious  than  the 
knife,  tumors  of  a  malignant  nature.  As  their  application,  to  use  Vel¬ 
peau’s  expression,  requires  neither  a  knowledge  of  anatomy  nor  of 
operative  surgery,  they  have  always  been  popular  with  many  who  have 
neither  the  knowledge  nor  the  skill  to  use  the  knife.  In  this  country, 
however,  they  have  never  enjoyed  any  very  extended  reputation;  and 
in  fact  they  have,  perhaps,  not  been  legitimately  employed  to  the  extent 
tliat  they  deserve,  especially  in  ulcerated  and  recurrent  cancers,  or  in 
those  so  situated  on  the  skin  and  muco-cutaneous  surfaces  as  not  to 
admit  of  being  very  readily  or  safely  extirpated  by  operation. 

The  great  objection  to  the  use  of  caustics  has  been  the  severity  and 
the  continuance  of  the  pain  induced  by  them,  lasting  not  only  for  hours, 
but  for  daj's — more  intense  and  prolonged  than  any  occasioned  by  the 
knife ;  and  as  it  is  usually  necessary,  in  order  to  destroy  effectually  the 
morbid  growth,  to  repeat  the  application  of  the  caustic  several  times, 
the  suffering  is  often  greater  than  the  most  resolute  patient  can  submit  to. 

The  chief  argument  in  favor  of  the  use  of  caustics  is  the  statement, 
that  cancers  thus  destroj^ed  are  less  liable  to  relapse  than  when  extirpated 
by  the  knife.  There  is,  however,  no  positive  evidence  before  the  pro¬ 
fession  in  proof  of  the  truth  of  this  dogma.  It  is  not  improbable  that 
the  chemical  action  of  the  caustics  may  extend  so  widely  into  neighbor¬ 
ing  tissues  as  to  destroy  or  render  unproductive  the  cancer-cells  or 
cancerous  plasma  by  which  the}^  are  infiltrated,  and  on  the  development 
of  which  the  local  recurrence  of  the  disease  depends.  But  it  is  impos¬ 
sible  to  believe  that  the  mere  method  of  removal  of  the  local  disease 
can  influence  the  constitutional  nature  of  the  cancer.  If  secondary 
infection  have  taken  place,  it  can  signify  very  little  whether  the  local 
disease  be  extirpated  by  the  knife  or  by  caustics.  If  no  cachexy  exist, 
it  appears  to  me  that  the  patient  must  be  equally  safe  in  whatever  way 
tlie  local  disease  is  removed,  provided  it  be  thoroughly  and  effectually 
extirpated.  Another  advantage  urged  in  favor  of  caustics,  in  the  correct¬ 
ness  of  which  Yelpeau  acquiesces,  is,  that  enlarged  lymphatic  glands  are 
more  likely  to  go  down  under  their  use  than  when  the  primary  cancer  is 
extirpated  by  the  knife.  Some  of  the  advocates  of  the  use  of  caustics 
in  the  treatment  of  cancer  pretend  that  the  particular  agent  employed 


660 


TUMORS. 


exercises  on  the  morbid  structure  a  specific  action,  which  is  confined  to 
it,  and  does  not  extend  to  the  neighboring  healthy  tissues.  But  this 
assertion  is  entirely  destitute  of  foundation. 

The  caustics  that  have  been  and  that  are  employed  in  the  treatment 
of  cancers  are  yeiy  various.  They  cannot  be  used  indiscriminately,  and 
consequently  we  must  briefly  consider  them  separately. 

1.  The  concentrated  mineral  acids^  especially  the  anhydrous  nitric 
and  sulphuric,  are  often  advantageously  emplo3’ed.  The  concentrated 
nitric  acid  ma}-  be  usefull}"  applied  to  small  superficial  cancerous  ulcers  ; 
it  rapidl}"  destro^'s  the  tissues,  and  does  not  spread  too  widel}',  but  it 
is  not  potent  enough  for  the  destruction  of  tumors.  The  glacial  sul¬ 
phuric  acid,  rubbed  into  a  black  paste  with  powdered  saffron,  is  the  caus¬ 
tic  which  Velpeau  extols  as  the  most  efficient  in  cancerous  tumors,  more 
particular!}"  if  of  a  fungating  or  bleeding  kind.  It  converts  the  part 
to  which  it  is  applied  into  a  thick,  hard,  carbonized  eschar,  with  but 
little  surrounding  inflammation  ;  and,  as  its  action  is  rapid,  the  pain  is 
not  prolonged.  On  the  separation  of  the  hard  slough,  a  health}^  granu¬ 
lating  cavity  will  be  left,  which  cicatrizes  rapidly  with  much  contraction. 
It  also  acts  as  a  hjemostatic,  rapidly  shrivelling  and  diying  up  large 
bleeding  and  discharging  fungi. 

2.  The  caustic  alkalies^  especially  potass  and  lime,  either  alone  or  in 
combination,  in  the  shape  of  the  Vienna  paste,  or  fused  into  sticks,  are 
veiy  energetic  in  their  action ;  but  the}"  have  the  disadvantage  of 
spreading  widely  if  applied  to  a  large  surface,  and,  by  softening  or 
dissolving  the  parts,  giving  rise  to  a  tendency  to  hemorrhage.  They 
may,  however,  be  advantageously  applied  to  small  cancers  of  the  face. 

3.  Various  mineral  salts^  more  particularly  the  chlorides  of  antimony, 
zinc,  and  bromine,  the  acid  nitrate  of  mercury,  and  the  arsenious  acid, 
are  often  employed  with  much  success  in  the  treatment  of  cancerous 
ulcers  and  growths. 

Of  the  various  chlorides^  that  of  zinc  is  the  most  useful.  This  is 
applied  by  being  made  into  a  paste  with  from  one  to  four  parts  of  flour, 
moistened  with  a  little  water,  or  by  the  pure  chloride  slightly  moistened 
being  spread  on  strips  of  lint.  It  must,  in  order  to  act,  be  applied  to 
a  raw  surface  ;  hence  it  is  customary  first  to  destroy  the  skin  with  nitric 
acid,  and  then  to  apply  the  chloride.  Canquoin  states  that  a  paste, 
made  of  equal  parts  of  the  chloride  and  of  flour,  .four  lines  in  thick¬ 
ness,  and  applied  for  forty-eight  hours,  destroys  the  parts  to  the  depth 
of  an  inch  and  a  half.  When  of  less  strength  and  substance,  its  action 
is  proportionately  limited.  There  are  two  methods  by  which  a  tumor 
may  be  attacked  and  destroyed  by  caustic  paste:  either  by  or  from  the 
circumference,  or  from  the  centre.  When  the  tumor  is  large  and  rapidly 
growing,  it  may  be  most  advantageously  destroyed  from  the  circumfe¬ 
rence,  at  its  junction  with  the  healthy  tissues.  This  may  be  done  by  the 
,plan  adopted  by  Maisonneuve — of  making  the  paste  into  small  sticks, 
or  pencils,  which  are  pushed  deeply  and  at  short  intervals  into  the  sub¬ 
stance  of  the  tumor  around  its  circumference,  so  that  its  tissue  becomes 
penetrated  by  the  action  of  the  caustic  in  all  directions,  and  its  A"itality 
thus  rapidly  destroyed.  In  small  tumors,  and  those  that  grow  with 
less  rapidity,  in  which  there  is  no  great  risk  of  the  rapidity  of  their 
growth  overtaking  and  passing  beyond  the  destructive  effects  of  the 
caustic,  the  paste  may  be  applied  to  and  around  the  centre,  and  the 
disease  in  this  manner  extirpated.  In  other  cases,  the  tumor  may  be 
deeply  and  rapidly  attacked  by  applying  a  layer  of  the  chloride  of  zinc 
l^aste  over  the  whole  of  its  surface.  The  slough  produced  by  this  appli- 


TREATMENT  OF  CANCER  BY  COMPRESSION. 


661 


cation  is  then  incised,  or  scored  longitudinally  at  equal  distances  of 
about  half  an  inch,  until  the  parts  beneath,  to  which  the  caustic  has  not 
penetrated,  are  reached  by  the  incisions  so  made  :  pieces  of  lint  covered 
wdth  the  deliquesced  chloride  are  put  into  them,  and  afterwards  fresh 
incisions  are  made  until  the  cauterizing  influence  has  extended  to  the 
bottom  of  the  tumor,  which  finally  sloughs  out  in  a  mass.  Of  the  utility 
of  the  chloride  of  zinc  as  a  caustic,  there  can  be  no  doubt ;  but  the 
chief  objection  to  its  use  lies  in  the  intensity  and  continuance  of  the 
pain  occasioned  by  it.  This,  however,  may  be  lessened  by  an  admixture 
of  about  a  sixth  part  of  morphia,  or,  as  L.  Parker  has  suggested,  by 
freezing  the  part  before  the  caustic  is  applied,  and  continuing  the  appli¬ 
cation  of  the  frigorific  mixture  during  the  time  of  the  action  of  the 
caustic.  Landolfl  has  recommended  the  use  of  the  chloride  of  bromine 
in  combination  with  those  of  gold  and  zinc ;  but  this  caustic  does  not 
appear  to  possess  any  decided  advantages  over  the  simple  chloride  of 
zinc,  and  is  objectionable  on  account  of  the  fumes  evolved  during  its 
use. 

Arsenic  exercises  a  powerful  action  upon  cancerous  growths,  and  is 
the  chief  ingredient  in  many  of  the  secret  preparations  used  by  empirics ; 
it  is,  however,  a  dangerous  agent,  and  excites  great  inflammation  and 
pain.  If  too  freely  used,  it  may  induce  poisoning,  and  not  a  few  deaths 
have  resulted  in  this  way ;  it  should,  accordingly,  not  be  applied  at  any 
one  time  to  a  surface  exceeding  a  shilling  in  size.  The  most  convenient 
mode  of  applying  it  appears  to  be  Manec’s  paste,  composed  of  one  part 
of  arsenious  acid  to  eight  of  cinnabar  and  four  of  burnt  sponge,  rubbed 
down  to  a  proper  consistence  with  a  little  water. 

Sulphate  of  zinc ^  dried,  finely  levigated,  and  made  into  a  paste  with 
glycerine,  or  an  ointment  with  axunge,  has  been  very  strongl}'  recom¬ 
mended  by  Simpson,  as  one  of  the  most  efficient  and  convenient  of  all 
caustics  in  rodent  and  cancerous  ulcers.  In  action  it  some’what  resem¬ 
bles  the  chloride  of  zinc,  but  is  less  painful. 

Of  all  these  caustics,  I  should  certainly  say  that  the  deliquesced 
cliloride  of  zinc  is  the  safest  and  the  most  efficacious,  more  particularly 
when  a  scirrhous  tumor  has  to  be  destroyed.  When  an  encephaloid 
fungus  has  to  be  attacked,  the  concentrated  sulphuric  acid  is  preferable, 
owing  to  its  coagulating  and  haemostatic  properties.  When  small  can¬ 
cerous  sores  have  to  be  destro3"ed,  the  nitric  acid,  the  arsenial  paste,  or 
the  chloride  of  zinc,  made  into  a  paste  with  flour  and  morphia,  may  very 
conveniently  be  used. 

Compression  is  a  plan  that  has  been  by  turns  greatly  extolled  and 
much  depreciated.  It  was  fully  tried  at  the  Middlesex  Hospital,  by 
Young,  more  than  forty  years  ago,  and  unfavorabl}^  reported  upon  by 
Sir  Charles  Bell  at  that  time;  it  consequent!}’' fell  into  disuse  in  this 
country,  but  was  revived  by  Recamier,  in  France,  and  employed  largely 
by  him.  Although  he  published  a  favorable  account  of  this  practice,  it 
made  but  little  progress  amongst  French  surgeons,  the  only  one  who 
seems  to  have  used  it  to  any  extent  being  Tanchou,  who  employs  a 
peculiar  topical  medication  conjoined  with  it.  In  this  country  the  prac¬ 
tice  fell  into  complete  oblivion  until  J.  Arnott  some  years  ago  invented 
a  mode  of  employing  pressure  by  means  of  an  elastic  air-cushion  ;  since 
which  time  it  has  been  extensively  employed  with  varying  degrees  of 
success. 

In  employing  pressure.  Young  principally  had  recourse  to  plasters 
and  bandages.  Recamier  used  amadou  applied  with  an  elastic  roller ; 
and  Tanchou  recommends  spring  pads,  under  which  small  bags  or  pieces 


662 


TUMOES. 


of  cotton-wadding  impregnated  with  various  medicinal  substances  are 
placed,  so  as  to  protect  the  skin  and  act  upon  the  tumor.  Arnott’s 
plan  consists  of  pressure  exercised  by  a  Macintosh  air-bag,  held  in  its 
place  b}^  straps,  and  pressed  upon  by  a  truss-spring,  the  pressure  exer¬ 
cised  by  which  may  be  made  to  vary  from  two-and-a-half  to  twelve  or 
even  sixteen  pounds.  These  different  plans  should  not  be  employed 
indiscriminately,  but  may  all  be  of  service  in  particular  cases.  I  have 
employed  them  all,  but  have  never  found  permanent  advantage  from 
any  of  them. 

The  first  question  that  necessarily  arises  in  reference  to  the  employ¬ 
ment  of  pressure  in  these  cases,  is  whether  it  can  effect  a  cure.  This  it 
could  only  be  expected  to  do  by  producing  atrophy,  and  subsequent 
absorption  in  the  strictly  local  forms  of  cancer.  The  only  case  on 
record,  with  any  pretension  to  a  conclusive  character  in  this  respect,  is 
one  related  by  Walshe  in  his  excellent  Treatise  on  Cancer^  of  the  cure 
of  a  tumor  of  the  breast  believed  to  be  cancerous,  by  compression.  But 
even  this  instance  I  cannot  look  upon  as  by  any  means  conclusive ;  for, 
although  no  one  can  entertain  a  higher  opinion  than  I  do  of  the  very 
remarkable  diagnostic  tact  possessed  by  Walshe,  yet  I  think  there  can 
be  no  doubt  in  the  mind  of  any  Surgeon  that  it  is  absolutely  impossible 
to  determine  in  many  cases,  by  any  amount  of  diagnostic  skill,  the  true 
nature  of  a  chronic  tumor  of  the  breast;  and,  in  fact,  we  constantly  see 
the  most  experienced  practitioners  find,  after  the  removal  of  the  tumor, 
that  it  was  of  a  different  character  from  what  they  had  previously 
anticipated.  This  difficulty  attaches  to  Walshe’s  case;  and  I  think  that 
we  possess  no  proof  that  the  tumor  of  the  breast,  which  underwent 
absorption  under  the  pressure  of  Arnott’s  apparatus,  was  of  a  truly 
cancerous  character,  and  that  it  might  not  have  been  a  chronic  mam¬ 
mary  tumor,  or  some  similar  growth  which  we  know  will  disappear 
under  this  kind  of  treatment. 

But,  if  compression  cannot  be  shown  ever  to  have  cured  a  cancer,  can 
it  not  retard  the  progress  of  this  disease,  or  relieve  the  sufferings  atten¬ 
dant  upon  it?  I  believe  that  in  some  cases  it  may  certainly  do  both, 
though  in  others  it  is  as  unquestionably  injurious.  It  appears  occasion¬ 
ally  to  retard  the  growth  of  the  tumor  when  applied  in  the  early  stage, 
simply  by  preventing  its  expansion,  and  perhaps  by  compressing  its 
nutrient  vessels,  and  so  diminishing  the  supply  of  blood  sent  to  it,  and 
by  causing  absorption  of  surrounding  inflammatory  infiltration  ;  in  these 
cases  likewise  it  relieves  for  a  time  the  pain  by  lessening  the  turgescence 
of  the  part.  In  other  cases,  however,  I  have  known  it  to  act  injuriously 
by  pressing  out  and  diffusing  the  tumor  more  widely,  appearing  to 
increase  the  tendency  to  implication  of  neighboring  parts,  and  occasion¬ 
ing  great  suffering.  When  the  tumor  is  ulcerated,  or  if  the  skin  covering 
it  be  inflamed,  pressure  cannot  be  employed  with  any  advantage;  and 
most  commonly  irritable  sensitive  patients  cannot  support  the  constric¬ 
tion  of  the  chest  that  it  induces. 

Excision. — With  regard  to  the  question  of  removing  cancers  by  the 
knife,  much  difference  of  opinion  exists  amongst  Surgeons,  for,  though 
all  deprecate  indiscriminate  recourse  to  this  means,  some  go  so  far  as  to 
dispute  the  propriety  of  ever  operating  for  this  disease,  whilst  others 
restrict  the  operation  to  certain  cases  of  a  favorable  character.  These 
questions  are  necessarily  of  considerable  importance,  and  require  atten¬ 
tive  examination. 

The  objections  that  have  been  urged  against  the  general  propriet}^  of 
operating  in  cases  of  cancer,  do  not  apply  so  much  to  the  operation 


EXCISION  OF  CANCER. 


663 


itself,  the  risk  attending  which  is  not  greater  than  that  of  other  opera¬ 
tions  of  similar  magnitude,  but  are  rather  based  on  the  supposition  that 
cancer  is  originally  a  constitutional  affection,  and  that  the  patient  is 
consequently  liable  to  speedily  suffer  from  a  return  of  the  disease,  so 
that  an  operation  that  is  at  least  unnecessary  will  have  been  performed. 
This  objection,  however,  as  has  already  been  remarked,  equally  applies 
to  all  other  means  of  local  removal,  as  by  caustics  or  compression,  as 
well  as  to  extirpation  by  the  knife ;  and,  if  carried  to  its  logical  conclu¬ 
sion  must  necessarily  preclude  any  attempt  at  removal,  by  any  means, 
of  the  local  disease.  That  this  objection,  so  far  as  the  liability  to  return 
of  the  cancerous  disease  after  operation  is  concerned,  is  to  some  degree 
a  valid  one,  is  undoubted;  the  experience  of  all  Surgeons  tending  to 
establish  the  fact,  that  the  majoritj^^  of  patients  operated  upon  for  cancer 
die  eventually,  and  usually  within  a  limited  time,  from  a  recurrence  of 
the  disease.  Thus,  A.  Cooper  states,  that  in  only  nine  or  ten  cases  out 
of  a  hundred  did  the  disease  not  return  in  three  vears;  and  Brodie  has 
found  that  it  generally  proves  fatal  in  two  or  three  years  after  the 
operation. 

After  removal  of  the  original  cancerous  tumor,  the  disease  may  return 
in  one  of  three  situations,  viz.,  in  the  cicatrix;  in  the  neighboring 
lymphatic  glands, with  or  without  the  cicatrix  having  been  involved;  or 
in  internal  organs.  The  mode  of  recurrence  in  these  different  parts 
is  obvious  enough.  When  the  disease  returns  in  the  cicatrix^  it  is  owing 
to  local  causes;  either  to  the  original  cancer  having  been  imperfectly 
removed,  when  recurrence  will  take  place  before  the  wound  is  healed,  or 
very  shortly  after  this  event;  or  to  the  widely  spread  infiltration  of 
cancer-germs  through  tissues  that  had  a  healthy  appearance,  when 
recurrence  will  take  place  after  a  lapse  of  some  weeks  or  months,  in 
the  shape  either  of  uniform  infiltration  of  the  cicatricial  tissue,  which 
assumes  the  appearance  of  an  elevated  hard  ridge  of  a  purplish-red 
color,  or  of  nodules  which  rapidly  coalesce.  AVhen  it  recurs  in  the 
lymphatic  glands^  tkey  have  doubtless  contained  the  cancer-germs  before 
the  removal  of  the  original  tumor.  They  become  hard,  infiltrated,  and 
often  form  secondaiy  grow'ths,  rivalling  the  primary  disease  in  size  and 
rapidity  of  development.  When  the  secondary  deposit  takes  place  in 
internal  organs^  it  is  usually  met  with  in  the  liver  or  the  lungs.  In 
such  cases  it  is  reasonable  to  presume  that  cancer-cells  or  portions  of 
cancer-plasma  enter  the  blood,  are  carried  into  the  general  current  of 
the  circulation,  and  are  deposited  just  like  the  pus-corpuscles  in  pyaemia 
in  these  organs,  there  forming  the  nuclei  of  new  growths. 

Recurrent  cancer,  in  whatever  situation  it  may  be  developed,  is  more 
rapid  in  its  course  than  the  primary  form  of  the  disease.  It  may  prove 
fatal  in  various  ways ;  by  exhaustion  from  local  discharges  or  hemor¬ 
rhage  ;  by  the  induction  of  an  anaemic  cachexy,  in  which  the  nutrition  of 
the  system  becomes  so  impaired  that  death  results ;  or  by  the  induction 
of  internal  disease  of  an  acute  character,  as  low  pneumonia,  pleuritic 
effusion,  or  ascites,  according  as  the  internal  deposit  is  thoracic  or  abdo¬ 
minal.  The  disease  is  especially  apt  to  recur  soon  if  the  skin  have 
become  involved,  if  the  lymphatic  glands  be  enlarged,  or  if  there  have 
been  constitutional  cachexy  before  the  operation ;  also  if  the  tumor  be 
growing  rapidly  at  the  time  of  removal,  and  especially  if  the  patient  be 
robust  and  strong,  with  a  florid  complexion. 

In  determining  the  question  of  operating  in  cases  of  cancer,  several 
points  of  great  importance  present  themselves  to  the  consideration  of 
the  Surgeon.  He  has  first  to  consider  whether  the  operation  is  likely 


664 


TUMORS. 


to  free  his  patient  completelj’’  from  the  affection ;  or,  in  the  event  of  its 
not  doing  so,  whether  at  least  life  may  not  be  prolonged  by  the  removal 
of  the  cancerous  tumor ;  and,  lastly,  even  though  the  patient  be  eventu¬ 
ally  carried  off  as  speedily  as  he  otherwise  would  have  been,  whether  his 
sufferings  may  not  be  much  lessened  b}^  the  removal  of  the  local  affection. 

The  principle  on  which  all  operations  for  the  removal  of  cancer  are 
undertaken  is  this ;  either  that,  the  disease  being  local  ah  initio^  the 
constitutional  and  secondary  manifestations  can  be  prevented  by  a 
timely  removal  of  the  local  and  primary  deposit ;  or  that,  even  if  the 
tumor  be  the  result  of  a  constitutional  proclivity  or  vice  developed  into 
activity  by  local  causes,  the  excision  of  this  local  deposit  removes  from 
the  system  a  new  centre  and  source  of  constitutional  infection ;  so  that 
if  the  operation  be  unsuccessful  in  completely  eradicating  the  disease,  it 
may  yet  be  productive  of  much  good  in  preventing  the  contamination  of 
the  system  from  this  new  centre  of  morbid  action.  The  two  following 
questions  will  therefore  present  themselves  to  the  Surgeon  in  considering 
this  subject. 

1.  Can  cancer  be  cured,  or  rathev  completely  extirpated  from  the 
system  by  excision  ? 

That  in  some  cases  a  cancerous  tumor  may  be  removed  with  every 
expectation  of  the  patient  being  completely  freed  from  the  disease, 
cannot,  I  think,  be  doubted;  although  it  maybe  true  that  such  instances 
are  rare.  Yet  they  occasional!}^  fall  under  the  observation  of  Sur¬ 
geons,  and  would  certainly  tend  to  prove  that  the  affection  is  not  in  all 
cases  constitutional,  and  that,  if  we  can  happily  succeed  in  removing  it 
during  its  local  condition,  there  is  a  good  prospect  that  the  patient  may 
be  rescued  from  a  return  of  the  affection.  Yelpeau  states  that  he  has 
perfectly  cured  patients  by  the  removal  of  cancerous  tumors — at  least 
that  no  return  has  taken  place  for  12,  15,  or  20  years  after  extirpation. 
The  evidence  of  Brodie  on  this  point  is  extremely  valuable  ;  writing  in 
1846,  that  eminent  Surgeon  states,  that  “So  long  ago  as  1832, 1  removed 
a  breast  affected  with  a  scirrhous  tumor,  and  the  lady  is  still  in  good 
health — at  least,  she  was  so  last  year.  Since  the  operation  she  has  mar¬ 
ried,  and  had  children.  Last  year  I  was  called  to  see  a  lady  on  account 
of  another  complaint,  on  whom  I  performed  the  operation  thirteen  years 
ago,  and  found  that  she  continued  free  from  the  old  disease ;  and,  very 
latel}^,  I  have  heard  of  another  lady  whose  scirrhous  breast  I  removed 
six  years  ago,  and  who  continues  well.”  The  opinion  of  Fergusson  is 
also  very  positive  on  this  point,  and  he  speaks  in  a  manner  with  which 
I  perfectly  agree.  He  sa3’s:  “Nevertheless,  as  excision  gives  the  only 
chance  of  security — a  point  on  which  most  parties  seem  to  agree — an 
operation  should  always  be  resorted  to,  provided  the  knife  can  be  carried 
beyond  the  supposed  limits  of  the  disease ;  and,  moreover,  I  deem  it  one 
of  the  duties  of  the  practitioner  to  urge  the  patient  to  submit  to  such  a 
proceeding.”  The  opinion  of  these  eminent  Surgeons,  supported  as  it 
is  by  the  general  practice  of  the  profession,  tends  to  show  that  in  some 
cases,  at  least,  the  disease  may  be  extirpated  from  the  system  by  ex¬ 
cising  the  tumor  before  the  constitution  has  become  implicated. 

2.  If  the  cancer  cannot  be  actually  cured  by  excision,  may  not  life  be 
prolonged  and  health  improved  by  an  operation  ? 

I  am  decidedly  of  opinion  that  this  is  possible;  and  that,  though  a 
patient  may  at  last  be  carried  off  by  some  of  the  recurrent  forms  of  can¬ 
cerous  disease,  health  may  have  been  improved,  life  ma}'  have  been 
prolonged,  and  much  suffering  may  have  been  spared,  by  a  timel}^  opera¬ 
tion.  It  may  often  be  observed  that,  after  the  cancer  has  been  removed, 


SELECTION  OF  CASES  FOR  EXCISION. 


665 


the  digestion  becomes  stronger  and  the  patient  gains  flesh  ;  the  color 
of  the  complexion  returns,  and  the. spirits  greatly  improve  ;  the  sj'stem 
being  relieved  from  a  source  of  local  irritation,  and  the  mind  from  a  cause 
of  disquietude  that  has  undermined  the  general  health  of  the  patient.  This 
is  more  particularly  the  case  in  encephaloid  cancer,  in  which  early  remo¬ 
val  of  the  disease  is  unquestionably  successful,  in  man}^  cases,  in  pro¬ 
longing  life.  The  observations  of  Paget  on  this  point  are  peculiarly 
valuable.  He  states  the  average  duration  of  life  of  those  patients 
laboring  under  this  form  of  the  disease,  in  whom  the  primary  affection 
is  removed,  to  be  about  twenty-eight  months ;  whilst  the  average  life  of 
those  in  whom  the  disease  is  allowed  to  run  its  course,  is  scarcely  more 
than  two  years. 

I  think  that  the  introduction  of  anaesthetic  agents  into  operative 
surgery  has  very  materially  affected  the  bearings  of  this  important 
question.  So  long  as  an  operation  was  a  source  of  great  pain,  and  of 
much  consequent  anxiet}'’  and  dread,  a  Surgeon  might  very  properly 
hesitate  in  subjecting  his  patient  to  severe  suffering  with  so  doubtful  a 
result ;  but  now  that  a  patient  can  be  freed  by  a  painless  procedure  from 
a  source  of  much  and  constant  annojmnce,  discomfort,  and  suffering, 
the  Surgeon  may  feel  himself  justified  in  thus  affording  him  a  few 
mouths  or  3'ears  of  comparative  ease,  though  he  ma}^  be  fully  aware  that, 
at  the  expiration  of  that  time,  the  affection  maj-  return,  and  will  then 
certainly  prove  fatal.  Even  then  the  patient’s  condition  ma}"  be  much 
improved;  for  the  recurrent  is  frequentl}^  less  distressing  to  him  than 
the  primaiy  disease,  since,  as  it  often  takes  place  in  internal  organs,  it 
is  not  attended  with  the  same  amount  of  local  pain  and  distress. 

In  discussing  the  propriety  of  operating  in  a  case  of  cancer,  the  Sur¬ 
geon  can,  however,  have  little  to  do  with  general  or  abstract  considera¬ 
tions.  He  has  to  determine  what  had  best  be  done  in  the  particular 
case ;  and  it  will  serve  him  little,  in  coming  to  a  conclusion  as  to  the 
line  of  practice  that  he  should  adopt,  to  refer  to  the  statistics  of  the 
gross  results  of  operations,  or  to  general  comparisons  between  the  results 
of  cases  that  are  not  operated  upon  and  those  that  are.  The  w'hole 
question  narrows  itself  to  the  point,  as  to  what  should  best  be  done  in 
order  to  prolong  the  life,  or  relieve  the  suffering,  of  the  particular  indi¬ 
vidual  whose  case  is  being  considered.  In  order  to  come  to  some 
definite  conclusion  on  this,  it  is  necessary  to  classify  the  different  cases 
of  cancer,  and  to  arrange  them  under  the  head  of  those  in  which  no 
operation  is  j ustifiable  ;  those  in  which  the  result  of  any  such  procedure 
would  be  very  doubtful ;  and  those  in  which  an  operation  is  attended 
with  a  fair  prospect  of  success. 

1.  Cases  not  proper  for  Operation _ a.  The  operation  ought  never  to 

be  performed  in  cases  where  several  cancerous  tumors  exist  in  different 
parts  of  the  bod}’’  at  the  same  time.  Here  the  disease  is  evidently  con¬ 
stitutional,  and  cannot  be  eradicated  by  an\^  series  of  operations,  h.  If 
the  cancerous  cachexy  be  strongly  developed,  or  if  the  disease  be  hered- 
itaiy,  it  is  useless  to  remove  a  local  affection  ;  as  the  malignant  action 
will  certainly  manifest  itself  elsewhere,  or,  perhaps,  even  speedil}^  return 
in  the  cicatrix,  c.  If  the  tumor  be  of  very  rapid  growth,  and  be  still 
increasing,  there  would  appear  to  be  so  vigorous  a  local  tendenc}''  to 
cancerous  deposit,  that  it  will  speedily  develop  itself  again  in  the 
cicatrix,  d.  If  the  tumor  be  so  situated  that  it  cannot  be  completely 
and  entirely  extirpated  b^"  cutting  widely  into  the  surrounding  parts,  it 
ought  not  to  be  meddled  with  ;  otherwise  the  affection  will  to  a  certaint^^ 
return  in  the  cicatrix  before  it  has  closed.  It  is  necessary  to  remove 


666 


TUMOES. 


not  only  the  tumor,  but  the  surrounding  tissues  to  some  extent,  even 
though  apparently  healthy,  e.  If  the  whole  of  the  atfected  organ,  as  a 
bone,  cannot  be  removed,  or  if  the  skin  and  glands  be  involved,  it  is 
useless  to  attempt  the  extirpation  of  the  growth,  as  a  speedy  relapse 
may  be  confidentl}^  looked  for.  f.  In  the  very  chronic  and  indurated 
cancers  of  old  people,  it  is  often  well  not  to  interfere,  as  in  these  cases 
the  affection  makes  such  slow  progress,  that  it  does  not  appear  in  any 
way  to  shorten  life,  and  the  mere  operation  might  be  attended  with 
serious  risk  at  an  advanced  age. 

2.  Doubtful  Cases. — Those  cases  in  which  the  result  of  an  operation 
is  extremely  doubtful,  but  in  which  no  other  means  offer  the  slightest 
prospect  of  relief,  have  next  to  be  considered,  a.  Cancers  of  the  eye, 
tongue,  and  testes,  belong  to  this  category  ;  for,  though  more  liable  to 
return  than  similar  affections  of  any  other  part  of  the  body,  yet  they 
may  be  considered  fit  cases  for  operation,  inasmuch  as  in  no  other  way 
has  the  patient  the  slightest  chance  of  being  relieved  from  his  disease. 
h.  In  cancers  that  are  already  ulcerated,  the  Surgeon  may  sometimes 
operate  in  order  to  give  the  patient  ease  from  present  suffering,  or, 
perhaps,  as  in  some  cases  recorded  by  Brodie,  with  a  view  of  prolonging 
the  duration  of  life ;  but  he  can  have  little  expectation  of  effecting  a 
permanent  cure.  c.  If  the  tumor  be  so  large,  or  be  so  situated,  that  its 
removal  cannot  be  undertaken  without  so  serious  an  operation  as  to 
occasion  in  itself  considerable  risk,  the  propriety  of  operating  is  always 
very  doubtful. 

3.  Gases  proper  for  Operation. — Those  cases  of  cancer  in  which  an 
operation  is,  in  my  opinion,  not  only  perfectly  justifiable,  but  should  be 
urged  upon  the  patient  as  affording  the  best  prospect  of  preserving  life, 
are  those  in  which  the  disease  has  appeared  to  originate  from  a  strictly 
local  cause  in  persons  otherwise  in  good  health,  in  whom  there  is  no 
cachexy  or  hereditary  taint.  If  the  tumor  be  of  scirrhous  character, 
slow  in  its  progress,  single,  distinctly  circumscribed,  without  adhesions 
to  or  implication  of  the  skin  or  glands,  and  more  especially  if  it  be 
attended  with  much  pain,  or  with  immediate  risk  to  life  from  any  cause, 
and  if  the  whole  of  the  growth,  together  with  a  sufficient  quantity  of 
the  neighboring  healthy  tissues  in  which  it  is  imbedded,  can  be  removed 
with  care,  the  case  may  be  looked  upon  as  a  fit  one  for  operation.  In  all 
encephaloid  cancers  also,  early  operation  should  be  practised  with  the 
view  of  prolonging  life. 

An  important  question  in  connection  with  operations  for  cancer  is,  at 
what  period  of  the  growth  they  may  be  done  with  the  best  prospect  of 
success.  Most  Surgeons,  taking  a  common-sense  view  of  this  question, 
are  in  favor  of  removing  the  affection  as  early  as  possible  :  feeling  that, 
as  it  is  difficult  to  say  when  the  local  form  of  the  disease  becomes  consti¬ 
tutional,  it  is  safer  to  remove  it  as  soon  as  its  true  nature  has  been 
ascertained  ;  and  I  confess  that  I  can  see  no  advantage  that  can  be 
gained  by  delay.  The  necessity  for  early  operation  in  medullary  cancer 
is  admitted  by  all ;  but  with  regard  to  scirrhous  cancer  the  opinion 
is  entertained  by  some,  that  in  many  cases  there  is  a  better  prospect  of 
success  if  the  operation  be  delayed :  and  it  is  stated  by  Hervez  de 
Chegoin  and  Leroy  d’Etiolles,  that  the  result  of  those  cases  operated  on 
after  the  cancer  has  lasted  for  some  time,  is  more  favorable  than  that  of 
those  in  which  an  early  operation  has  been  done ;  the  cancer  often 
appearing  to  be  arrested  in  its  development,  and  to  localize  itself,  as  it 
becomes  more  chronic,  and  having  consequently  a  less  tendency  to 
speedy  return  after  removal.  That  the  result  of  operations  in  such 


GENERAL  CHARACTERS  OF  EPITHELIOMA.  667 

selected  cases  is  favorable, is  probable  enough;  as  it  may  be  reasonably 
supposed  that  the  more  active  varieties  of  cancer,  those  that  possess 
the  greatest  amount  of  vegetative  activity  and  of  reproductive  power, 
may  have  acquired  a  condition  unfavorable  to  operation,  or  may  even 
have  carried  olf  the  patient  before  any  period  of  arrest  in  their  growth 
has  occurred,  during  which  their  extirpation  could  be  practised  with  a 
fair  prospect  of  success.  In  delaying  operation  there  is,  however,  much 
danger  lest  valuable  time  be  lost  in  the  employment  of  means  which, 
ineffective  in  arresting  the  disease,  may  become  positively  injurious  by 
allowing  time  to  the  morbid  growth  to  contaminate  the  glandular 
system,  or  to  extend  widel}''  through  neighboring  tissues.  If  we  look 
upon  a  cancer  as  a  parasitic  growth  which  must  necessarily  destroy 
life,  either  by  changes  taking  place  in  its  own  substance  or  by  the  con¬ 
tamination  of  the  system,  and  which  is  intractable  to  all  medication, 
whether  topical  or  constitutional,  we  must  regard  its  extirpation  as  the 
only  resource  that  Surgery  offers ;  and  we  may  assuredly  infer,  that  the 
liability  to  constitutional  infection  and  wide-spread  local  contamination 
will  be  less  in  proportion  to  the  earl}’’  removal  of  the  morbid  mass. 

Epithelioma,  though  closely  allied  to  the  true  cancers,  differs  from 
them  in  so  many  important  respects  that  it  requires  to  be  considered  as 
a  distinct  affection.  It  resembles  the  true  cancers  in  its  tendency  to 
local  infiltration  and  ulceration,  in  its  extension  to  the  l3"mphatic  system, 
and  in  the  induction  of  death  by  cachexy.  It  differs  from  them  in  its 
anatomical  structure,  in  being  invariably  seated  in  the  mucous,  muco¬ 
cutaneous,  and  more  rarely  the  cutaneous  structures — always  primarily 
on  a  mucous  or  cutaneous  surface,  where  epithelial  cells  are  naturally 
found,  and  in  its  being  rarely  attended  by  secondary  deposits  in  the 
viscera.  Some  writers  have  gone  so  far  as  to  deny  any  relationship 
between  these  growths  and  the  true  cancers,  and  others  again  have 
looked  upon  them  as  semi-cutaneous  formations  (cancroid  of  Virchow) ; 
there  can,  however,  be  little  doubt  that  a  true  cancer  exists,  presenting 
a  very  marked  resemblance  to  epithelial  structures,  and  that  this  is  per¬ 
fectly  distinct  both  histologically  and  cliuicall}’’  from  other  formations 
usually  grouped  together  under  the  title  of  epithelioma.  These  are  for 
the  most  part  papillary  and  glandular  developments,  and  do  not  present 
any  heterologous  structure.  In  the  true  epithelial  cancer  the  cells  are 
developed  in  the  substance  of  the  corium,  and  not  upon  the  free  surface; 
whilst  in  the  other  varieties  the  cells  are,  primarily  at  least,  developed 
upon  the  surface  of  the  papillae,  or  within  gland-tubes,  and  become  only 
secondaril}^  included  in  the  corium.  It  is  often  difficult  at  a  late  stage 
to  distinguish  these  various  forms  from  one  another,  as  they  present  the 
same  peculiarities  of  structure. 

Situation  and  Progress. — Epithelioma,  rare  in  the  young,  is  common 
in  middle-aged  or  elderly  people,  the  tendency  to  it  increasing  in  propor¬ 
tion  as  age  advances.  In  this  respect  it  follows  the  course  of  other  can¬ 
cers.  It  is  generally  occasioned  by  the  long-continued  or  frequently 
repeated  application  of  some  source  of  irritation,  and  ma}’’  thus  be 
established  in  constitutions  otherwise  perfectly  health3\  Thus,  the 
irritation  of  a  broken  tooth  upon  the  tongue  or  cheek  ma}^  produce 
epithelioma  of  those  parts.  The  scrotum  in  chimney-sweepers  not 
unfrequently  becomes  the  seat  of  epithelioma,  in  consequence  of  the 
lodojement  and  irritation  of  soot  in  its  ruQ:8e.  The  muco-cutaneous  sur- 
faces  are  its  true  habitat;  it  chiefly  occurs  in  the  lips  (Fig.  235),  tongue, 
mouth,  ej^elids,  penis,  vagina,  and  anus.  It  is,  however,  also  met  with 
in  the  cutaneous  surfaces  of  the  face,  the  hands,  the  feet,  and  the  scro- 


668 


T  U  M  0  K  S . 


Epithelioma  of  the  Lower  Lip. 
about  21. 


Male ; 


turn  ;  and,  indeed,  may  occur  upon  any  cutaneous  surface,  although 
there  can  be  no  doubt  tliat  those  tubercles  and  malignant  ulcerations 
that  occur  in  the  purely  cutaneous  surfaces  of  the  extremities  and  trunk 
are  not  unfrequently  scirrhous.  It  commences  either  as  a  small  flat 
tubercle  or,  wart,  which  rapidly  ulcerates  ;  or  it  appears  from  the  first  as 
an  intractable  fissure  or  ulcer  of  limited  size,  with  hard  and  everted 

edges,  and  a  foul  surface.  Such  an  ulcer 
as  this  may  not  only  attack  and  destroy 
the  soft  parts  of  its  neighborhood,  but 
may  equally  produce  its  destructive  action 
on  bones,  penetrating  deeply  into  their 
structure  and  eroding  them.  It  slowly 
spreads,  and  appears  at  first  to  be  local ; 
but  after  a  time,  contaminating  the  glands 
in  the  neighborhood,  it  induces  cachex}^ 
and  destroys  the  patient  by  exhaustion. 
Epithelioma,  however,  is  not  always  ex¬ 
ternal:  it  may  develop  from  deep  mucous 
surfaces.  Many  of  the  so-called  malig¬ 
nant  polypi  of  the  nose — naso-pharyngeal 
and  antral  tumors — are  of  this  nature.  I 
have  seen  an  epithelioma  as  large  as  a 
small  orange,  developing  in  this  situation,  and  passing  into  the  orbit 
and  to  the  cheek.  In  the  larynx,  pharynx,  and  oesophagus,  the  bladder, 
the  uterus,  and  other  organs  of  this  kind,  it  is  also  met  with.  In  fact, 
from  any  part  of  the  body  that  is  naturally  provided  with  epithelium, 
and  from  such  surfaces  only,  epithelioma  may  be  developed.  The  onl}'” 
apparent  exception  to  its  occurrence  on  the  surface  covered  by  epithelial 
or  epidermic  scales  with  which  I  am  acquainted,  is  its  appearance  as  a 
submucous  tumor  in  the  mouth  and  uterus,  of  which  I  have  more  than 
once  seen  instances  in  both  of  these  situations  ;  the  tumors  varying  in 
size  from  a  cherry  to  a  small  walnut,  round,  pedunculated,  and  fibrous 
looking,  but  presenting  after  removal  the  characteristic  epitlieliomatous 
structure.  An  epithelioma  developing  upon  the  integumental  surfaces 
may  extend  deeply,  and  thus  affect  or  destroy  subjacent  organs.  Thus 
from  the  eyelids  it  may  invade  and  disorganize  the  ej^eball ;  from 
the  scrotum  it  may  implicate  the  testis  ;  from  the  skin  it  may  penetrate 

into  and  destroy  the  subjacent 
bones,  as  we  see  in  the  face  and 
occasionally  in  the  tibia.  Exten¬ 
sive  secondary  deposits  in  the  lym¬ 
phatic  glands  in  the  vicinity  of 
the  parts  affected,  even  deep  in  the 
submaxillary,  iliac,  and  pelvic  re¬ 
gions,  invariably  take  place  after 
the  disease  has  lasted  for  some  time. 

Structure. — On  examination,  an 
epithelioma  will  be  found  to  be  com¬ 
posed  of  a  fibrous  basis,  with  a  larg'e 
quantity  of  condensed  and  morbid 
scales  closely  packed  upon  it  (Fig. 
236) ,  closely  resembling  those  of  the 
ei)idermis  and  epithelium.  Their 

Sectioa  of  an  Epithelioma  of  the  Cheek,  showing  ,  ,  • 

,,  1  ^  11  -.i-  *1  V.  arrana;ement,  however,  is  ditterent 

the  formatloa  of  Epithelial  Cells  withia  the  sub-  ’  *  •  i  t  i 

stance  of  the  true  Skin,  flOIU  01  tll6  DOirQfll  G]^^lt)ilGlicll 


Fig.  236. 


GENERAL  CHARACTERS  OF  EPITHELIOMA. 


669 


tissues;  they  present  a  remarkabl}"  withered  appearance,  and  contain 
a  small  and  rather  shrivelled  nucleus  ;  they  measure  from  to 

■g^oth  or  of  inch  in  diameter,  and  are  often  much  flattened 

(Figs.  237,  238).  They  are  sometimes  packed  together  in  masses 


Fig.  237. 


Cells  from  Epithelial  Cancer  of 
Lower  Lip. 


Fig.  238. 


Cells  from  Chimney-sweep’s 
Cancer. 


or  halls,  assuming  a  concentric  arrangement,  hence  termed  “  con¬ 
centric  globes”  (Fig.  239),  and  in  these  present  a  somewhat  fibrous 
appearance.  According  to  Simon,  however,  this  fibrous  structure  is 
deceptive,  depending  upon  the  scales  being  much  attenuated  and  woven 
together.  These  nest-like  formations  are  produced,  according  to  Yir- 
chow,  by  the  remarkable  tendency  to  endogenous  cell-growth  exhibited 
by  some  of  these  cells,  and  the  development  of  large  “  brood-spaces” 
within  them :  this  appears  to  be  due  in  most  cases  to  the  enlargement  of 
the  nucleus.  The  pressure  produced  by  this  formation  of  brood-spaces, 
and  the  endogenous  cell-growth  accompanying  it,  causes  the  cells  to  be¬ 
come  flattened  and  to  take  on  a  concentric  arrangement.  The  forma¬ 
tion  of  false  nests,  which  may  often  be  seen  in  papillary  and  glandular 
growths,  is  due  to  the  development  of  cells  in  the  limited  spaces  and  to 
consequent  concentric  pressure,  but  never  to  the  enlargement  of  central 
cells  and  consequent  excentric  pressure.  In  many  cases  they  are  inter¬ 
mixed  with  globular  bodies,  and  in  others  with  cells  of  various  shapes, 
resembling  those  found  in  the  more  trul}" 
cancerous  diseases  (Fig.  239).  But  although 
the  local  characters  of  an  epithelioma  may 
in  some  cases  be  distinguishable  with  diffi¬ 
culty  from  those  of  true  cancer,  there  is  a 
very  important  pathological  difference  be- 
tw’een  the  two  diseases  ;  for  in  Epithelioma 
tliose  secondary  affections  of  the  viscera 
which  are  so  common  in  and  characteristic 
of  true  cancer  rarely  occur.  AVhen  epithe¬ 
lioma  proves  fatal,  it  is  usually  by  the  pro¬ 
gress  of  the  local  disease  ;  by  its  extensive 
ulcerations  ;  by  the  contamination  of  the  neighboring  lymphatic  glands  ; 
and  by  the  consequent  induction  of  a  constitutional  cachexy  and  malnu¬ 
trition,  with  exhaustion  of  the  system.  But  those  secondary  tumors 
which  are  met  with  in  the  liver,  lungs,  etc.,  indicative  of  a  deeper  con¬ 
tamination  of  the  sj^stem  than  is  shown  by  glandular  deposits,  and 
wdiich  are  the  characteristic  and  almost  invariable  accompaniment  of 
other  forms  of  cancer  seldom  occur  in  epithelioma. 

Diagnosis. — The  diagnosis  of  epithelioma  from  true  cancer  is  not 
always  easy.  The  principal  points  that  would  guide  the  Surgeon  are  : 


Fig.  239. 


Concentric  Globes  of  Epithelioma. 


670 


TUMORS. 


1.  The  almost  invariable  occurrence  of  the  epithelioma  on  the  mucous 
or  muco-cutaneous  surfaces.  2.  Its  early  ulceration ;  often  from  the 
very  commencement,  as  the  primary  form  of  the  disease.  3.  The  ten- 
denc}’^  to  spread  b}?-  ulceration  rather  than  by  new  deposit.  4.  The  ori¬ 
gin  of  the  disease  from  some  evident  source  of  external  irritation.  5. 
The  absence  of  all  evidence  of  contamination  of  internal  organs.  In 

O 

making  the  diagnosis,  it  must  be  borne  in  mind  that  scirrhus,  when 
affecting  the  mucous  or  cutaneous  surfaces,  usually  commences  as  a 
tubercle  ;  and  that,  w'hen  this  ulcerates,  the  base  of  the  ulcer  has  a  hard 
and  deeplj^  infiltrated  feel,  extending  for  some  distance  into  the  tissues, 
whereas  epithelioma  is  never  superficial,  and  is  ulcerated  rather  than 
tuberculated  and  infiltrated. 

The  Prognosis  of  epithelioma  is  far  more  favorable  than  that  of  true 
cancer  in  any  of  its  varieties. 

Treatment. — The  treatment  of  epithelioma  is  much  more  satisfactory 
than  that  of  the  true  varieties  of  carcinomatous  disease  which  we  have 
just  been  considering,  inasmuch  as  this  partakes  more  of  the  characters 
of  a  local,  and  less  of  a  constitutional  affection,  than  the  true  forms  of 
cancer.  Constitutional  treatment  is,  I  believe,  as  ineffectual  in  epithe¬ 
lioma  as  in  the  other  forms  of  cancer  ;  but  earl}"  and  free  removal  by 
excision  or  ligature,  or  complete  destruction  by  caustics  will  not  un¬ 
commonly  permanently  rid  the  patient  of  this  affection.  Indeed,  if  the 
operation  be  done  sufficiently  early,  I  believe  there  is  little  liability 
to  relapse.  I  am  acquainted  with  several  cases  in  which  from  six  to 
ten  years  have  elapsed  from  the  date  of  the  operation,  without  a  sign 
of  a  tendency  to  recurrence  of  the  disease.  Paget  refers  to  a  case  in 
which  thirty  years  elapsed  after  the  removal  of  a  scrotal  cancer  before 
the  reappearance  of  the  disease.  But  great  risk  of  recurrence  arises 
from  the  delay  of  operation  and  the  employment  of  inefficient  means. 
The  operation  may  be  successfully  practised  at  any  age.  I  have  re¬ 
moved  an  einthelioma  of  the  tongue  from  a  man  85  3"ears  of  age  with 
perfect  success. 

Excision  should  always  be  preferred  whenever  practicable,  and  should 
be  done  as  soon  as  the  nature  of  the  disease  is  recognized,  the  part  being 
thoroughly  removed  together  with  a  wide  margin  of  tissue  on  each  side 
of  and  beneath  it,  so  that  no  cancer-germs  may  be  left  from  which  new 
growths  can  spring.  When  the  neighboring  lymphatic  glands  are  but 
slightly  enlarged,  the  operation  may  still  be  done  ;  the  glandular  en¬ 
largement,  which  may  be  dependent  on  irritation,  gradually  subsiding. 
If,  however,  the  enlargement  be  more  considerable  the  affected  gland 
must  be  extirpated ;  but  if  there  be  a  chain  of  enlarged  glands,  more 
especially  in  the  deeper  cavities,  no  operation  should  be  undertaken,  as 
the  disease  will  then  have  become  constitutional.  If  the  disease  be 
situated  on  one  of  the  extremities,  as  the  hand  or  foot,  partial  or  com¬ 
plete  amputation  may  be  the  safest  procedure  ;  and  such  cases  are  less 
liable  to  relapse  than  others  in  which  such  free  extirpation  is  not  admis¬ 
sible. 

The  Ligature  may  be  advantageously  emplo3^ed  when  the  cancer  is  so 
situated  that  excision  is  impracticable,  either  on  account  of  dangerous 
hemorrhage,  or  from  the  impossibility  of  effectually  extirpating  the  dis¬ 
ease.  The  part  having  been  well  insulated,  and  effectual!}"  strangled  by 
stout  whip-cord  ligatures,  sloughs  and  separates  in  a  few  days. 

By  means  of  the  Ecraseur  (Fig.  240),  cancroid  and  other  growths  of 
considerable  size  are  removed  with  little  or  no  hemorrhage,  in  the  course 
of  a  few  minutes,  by  a  process  of  rapid  strangulation  and  crushing  in  a 


TREATMENT  OF  EPITHELIOMA. 


671 


linear  direction.  The  ecraseur  consists  of  a  loop  of  chain  or  fine  steel 
or  twisted  wire,  which,  having  been  passed  over  the  tumor  or  through 
the  tissues  to  be  removed,  is  gradually  tightened  by  a  mechanism  in  the 
stem  to  which  it  is  attached.  In  applying  this  instrument  it  is  often 


Fig.  240. 


necessary,  first  of  all,  to  insulate  and  raise  the  tumor  to  be  removed  by 
passing  a  thread  through  or  under  it  (Fig.  241)  ;  and  then,  having  ap¬ 
plied  the  chain’s  loop  around  its  base,  to  tighten  this  and  efifect  the 


Fig.  241. 


Ecraseur  Applied. 


strangulation  by  working  the  handle  every  ten  or  fifteen  seconds,  until 
the  mass  is  detached.  The  resulting  wound  is  small  and  puckered  in, 
and  often  heals  with  but  little  trouble.  If  the  mass  to  be  removed  be 
large,  two  or  more  ecraseurs  may  be  used  at  the  same  time,  the  chains 
having  been  passed  through  the  tissues  by  means  of  a  needle.  The 
action  of  the  Ecraseur  differs  according  to  the  kind  of  instrument  used. 
Chassaignac’s  original  ecraseur,  armed  with  a  steel  chain,  and  having  a 
to-and-fro  movement,  acts  like  a  saw.  That  which  is  now  often  em¬ 
ployed  {vide  vol.  ii..  Diseases  of  the  Tongue)  acts  as  a  simple  constrictor; 
and  its  use  is  therefore  less  likely  to  be  followed  by  hemorrhage.  This 
instrument  appears  to  me  to  be  chiefiy  applicable  to  cases  in  which,  as 
in  cancroid  ulcer  of  the  tongue,  excision  is  hazardous  on  account  of  the 
hemorrhage  attending  it,  while  the  ligature  is  objectionable  on  account 
of  the  fetor  and  discharge  resulting  from  the  slow  separation  of  the 
constricted  mass,  which  sloughs  and  becomes  putrescent.  The  French 
Surgeons,  however,  extend  the  use  of  the  ecraseur  to  many  cases  in 
which  in  this  country  the  ligature  or  the  knife  is  preferred.  They  sup¬ 
pose  that  p3*£emia  is  less  likely  to  follow  removal  by  this  instrument 
than  b}^  the  more  ordinary  means,  purulent  absorption  less  readily 
occurring  while  the  vessels  on  the  cut  surface  are  crushed  together. 
Whether  this  be  really  so,  remains  to  be  proved. 

Caustics. — In  some  instances,  the  disease  being  so  situated,  as  in  some 


672 


TUMORS. 


parts  of  the  face,  or  in  the  deeper  cavities  of  the  bod3",  that  it  cannot  be 
dissected  out,  the  application  of  caustics  will  be  useful  in  procuring  its 
removal ;  but,  if  these  agents  be  emplo^-ed,  care  should  be  taken  that 
they  be  freelj^  applied  and  be  sufficiently  strong,  so  as  thoroughl}’-  to 
destro}’’  the  whole  of  the  morbid  textures.  Inefficient  caustics,  such  as 
nitrate  of  silver,  irritate  and  do  not  destroy  the  tissues  to  which  they 
are  applied,  and  in  this  way  do  much  mischief.  Inflammation  is  excited 
around  the  cancroid  growths,  plastic  exudation  takes  place,  and  this  be¬ 
comes  rapidly  infiltrated  b}’"  the  abnormal  structure,  which  thus  extends 
with  much  greater  rapidity'  than  would  otherwise  have  been  the  case  ; 
the  plastic  matter  being  from  its  veiy  formation  contaminated  with 
cancer-cells.  The  best  caustic  preparations  are  the  concentrated  sul¬ 
phuric  acid,  arsenic,  and  chloride  of  zinc  paste,  fused  potassa  cum  calce, 
the  potassa  fusa,  the  Vienna  paste,  and  the  acid  nitrate  of  mercury 
{vide  p.  660).  All  of  these  ma}^  be  applied  successfully',  though  they' 
should  not  be  used  indiscriminately.  The  chloride  of  zinc  and  the 
Vienna  paste  are  most  useful  when  the  ulcerated  surface  is  large,  and 
indurated  at  its  base  or  edge.  The  acid  nitrate  of  mercury  should  only 
be  employed  w'hen  the  sore  is  small,  superficial,  irregular,  and  without 
much  induration.  In  such  cases  also,  the  arsenical  pastes  and  powders 
already-  described  are  very'  useful. 

When  a  recurrence  takes  place  after  operation  for  epithelioma,  it  is 
either  by'  a  fresh  deposit  of  cancerous  matter  in  the  cicatrix,  or  else  by 
the  neighboring  ly'uiphatic  glands  which  had  been  contaminated  before 
the  operation,  continuing  to  enlarge  and  at  last  ulcerating,  and  thus  de¬ 
stroying  the  patient  by'  cachexy^  and  exhaustion,  but  (except  in  very 
rare  cases)  without  the  occurrence  of  secondary  deposits  in  internal 
organs. 


EXCISION  OF  TUMORS. 

In  describing  the  different  forms  of  ency'sted  tumor,  the  operative 
procedures  necessary  for  their  removal  have  been  adverted  to.  We  may 
now  conveniently'  consider  the  steps  that  are  generally’-  necessary  for  the 
extirpation  by'  the  knife  of  solid  tumors  from  the  soft  parts. 

In  the  removal  of  tumors,  the  first  point  to  be  attended  to  is  the  ar¬ 
rangement,  shape,  and  direction  of  the  necessary  incisions.  These 
should  not  only'  have  reference  to  the  size  of  the  growth,  extending  well 
bey'ond  it  at  each  end,  but  must  also  be  planned  with  due  regard  to  sub¬ 
jacent  parts  of  importance.  As  a  general  rule,  they'  should  be  carried  in 
the  direction  of  the  axis  of  the  limb  or  part,  and  parallel  to  the  course  of 
its  principal  vessels  ;  they'  must  not  only'  extend  over  the  whole  length  of 
the  tumor,  but  also  a  little  bey'ond  it  at  each  end  :  no  cross-cuts  should 
be  made,  if  they  can  be  avoided^  and  this  may  usually'  be  done  by'  atten¬ 
tion  to  the  proper  position  and  extension  of  the  linear  incisions.  In 
most  cases,  no  skin  should  be  removed,  a  simple  cut  being  made ;  but  if 
the  iutegumental  tissues  be  either  very'  abundant  and  loose,  or  else  ad¬ 
herent,  an  elliptical  portion  of  them  may  be  excised  together  with  the 
tumor.  In  other  instances,  again,  a  semilunar  flap  of  integument  may 
with  advantage  be  turned  up  from  the  tumor,  the  surface  of  which  is 
then  fairly'  exposed  ;  this,  however,  can  only'  be  done  in  some  simple 
tumors,  such  as  fatty  growths.  The  flaps  covering  the  growth  should 
then  be  freely'  but  cautiously'  dissected  back,  so  as  to  expose  its  sides 
and  base  ;  as  these  are  approached,  and  the  Surgeon  reaches  the  neigh¬ 
borhood  of  its  more  important  and  deeper  connections,  increased  care 


EXCISION  OF  TUMORS. 


673 


will  be  necessaiy,  as  it  not  imfrequentl}’  happens  that  the  tumor  is  in 
more  important  relations  with  deep-seated  bloodvessels  and  nerves  of  a 
large  size  than  would  at  first  appear. 

When  practicable,  the  deep  dissection  will  best  be  commenced  and 
carried  out  from  that  part  of  the  base  of  the  tumor  into  which  the  prin¬ 
cipal  bloodvessels  appear  to  enter ;  they  are  thus  early  cut,  and  being 
once  ligatured  give  no  further  trouble,  which  they  would  do  were  they 
divided  from  the  direction  of  their  branches  towards  the  trunk,  when  at 
each  successive  stroke  of  the  knife  a  fresh  portion  of  the  vessel  would 
be  touched.  In  cariying  on  this  deep  dissection,  the  operator  should 
proceed  methodically  from  one  side  of  the  tumor  to  the  other,  the 
assistants  holding  aside  the  skin  so  as  to  give  as  much  room  as  possible, 
whilst  the  Surgeon  himself,  seizing  the  mass  with  his  left  hand,  or  with 
a  large  double  hook  or  vulsellum,  and  dragging  it  well  forwards,  uses 
the  knife  by  successive  strokes,  but  in  a  leisurel}'  and  careful  manner, 
avoiding  all  undue  haste,  until  he  completely  detaches  it  from  its  c,on- 
nections.  The  safety  of  contiguous  important  structures  will  be  best 
secured  by  keeping  the  edge  of  the  knife  constantly  directed  towards 
the  tumor,  if  this  be  non-malignant ;  by  attention  to  this  rule,  I  have 
seen  Liston  remove  tumors  with  remarkable  facility  and  ease  from  the 
neighborhood  of  most  important  parts.  If,  however,  the  growth  be 
malignant,  the  incisions  must  be  made  wide  of  the  disease  into  the 
healthy  structures  around;  unless  this  be  done,  portions  of  the  tumor 
may  be  left  from  which  fresh  growths  will  rapidl}’  sprout,  or  cancer-cells 
may  impregnate  the  neighboring  tissues  through  which  they  are  scattered, 
and  may  eventually  become  so  manj’^  fresh  centres  of  malignant  action. 
After  the  tumor  has  been  removed,  it  must  be  carefxdly  examined^  with 
the  view  of  ascertaining  whether  it  be  entire  :  and,  if  aii}’^  portions  have 
been  left,  these  must  be  properly  dissected  out.  In  some  situations,  as 
the  axilla,  the  side  of  the  neck,  or  the  groin,  where  the  relations  are  of 
great  importance,  the  less  the  edge  of  the  knife  is  used  the  better,  and 
the  growth  should  be  enucleated  by  the  Surgeon’s  fingers  or  by  the 
handle  of  the  scalpel. 

The  Surgeon  should  never  undertake  the  removal  of  tumors  that  can- 
not  be  wholly  and  entirely  extirpated,  as  the  part  left  will  alwa3^s  grow 
with  greatly  increased  rapidity*,  often  assuming  a  fungous  character  ; 
this  is  especiall}^  the  case  with  malignant  tumors,  the  rapidit}"  of  increase 
of  which  is  greatly  augmented  b}"  partial  operations.  Should,  however, 
the  Surgeon  have  been  deceived  as  to  the  depth  and  connections  of  the 
mass,  if,  for  instance,  he  find,  after  commencing  his  operation,  that  the 
tumor  extends  more  deepl}^  than  had  been  anticipated,  and  comes  into 
such  close  relation  with  important  vessels,  as  at  the  summit  of  the  axilla 
or  in  the  perinjeum,  as  to  prevent  him  from  dissecting  it  out  without 
imminent  risk  of  destroying  the  patient,  the  onh^  alternative  left  is  one 
that  I  have  seen  Liston  adopt,  and  have  had  occasion  mj’self  to  practice; 
viz.,  to  throw  a  strong  w'hipcord  ligature  above  the  apex  of  the  growth 
as  high  up  as  practicable,  and  then  to  cut  oflf  eveiything  below  this.  On 
the  separation  of  the  ligature,  any  portion  of  the  tumor  that  has  been 
included  will  be  brought  awaj^  as  if  it  had  been  removed  by  the  knife. 

In  some  cases  it  will  be  found,  after  dividing  the  fascia  covering  the 
tumor,  that  the  attachments  of  the  growth  are  not  so  firm  or  deep  as 
had  been  previously  expected  ;  this  is  especially  the  case  in  some  large 
tumors  springing  from  the  side  of  the  neck  and  the  parotid  region,  or 
in  the  groin.  The  growth  may  then  often  be  removed  in  a  great  measure 
b^"  separating  the  areolar  tissue  with  the  handle  of  the  knife,  merely 
YOL.  I. — 43 


674 


SCEOFULA  AND  TUBEECLE. 


dividing  those  portions  of  the  deeper  attachments  that  are  peculiarly 
dense. 

The  wound  that  is  left  after  the  removal  of  a  tumor  usually  unites 
partly  by  adhesive  inflammation,  and  partly  by  the  second  intention ;  it 
should  be  lightly  dressed,  the  edges  being  brought  together  by  strips  of 
I)laster  and  covered  by  water-dressing,  and,  if  large,  supported  by  a  com¬ 
press  and  bandage.  Sutures  should  not  be  employed  unless  absolutely 
necessary  ;  they  irritate,  and  their  removal  is  very  painful. 


CHAPTER  XX XY. 

SCROFULA  AND  TUBERCLE. 

These  two  diseases  are  intimately  connected  with  certain  morbid 
states  of  the  lymphatic  system,  and  have  by  many  writers  been  con¬ 
sidered  merel}^  as  different  expressions  of  the  same  constitutional  state ; 
they  ma}”,  however,  with  greater  propriet}’’,  be  viewed  as  the  results  of  a 
departure  in  different  directions  from  the  normal  nutrition  of  the  same 
system  of  elementary  tissues.  The  two  conditions  are  undoubtedly 
closely  related  in  their  causes  and  their  effects,  and  may  even  coexist  in 
the  same  individual ;  still,  in  their  most  typical  forms  they  present  very 
marked  difterences,  which  serve  to  distinguish  them  clinically  as  well  as 
pathologically. 

Scrofula. — By  this  term  is  meant  a  peculiar  constitutional  condition, 
either  hereditaiy  or  acquired,  that  gives  rise  to  chronic  inflammatory 
changes  in  certain  tissues  or  organs,  which  are  alwa3^s  accompanied  by 
more  or  less  swelling  of  the  proximate  Ij^mphatic  glands.  The  affections 
to  which  an  individual  so  constituted  is  most  subject,  are  catarrhal 
inflammations  of  the  skin  and  mucous  membranes,  and  subacute  inflam¬ 
mations  of  the  periosteal  and  synovial  structures.  The  products  of 
these  inflammatoiy  changes  often  undergo  degeneration  and  obsoles¬ 
cence,  giving  rise  to  cheesy  masses,  which  are  not  unfrequently  con¬ 
founded  with  those  derived  from  true  tubercle.  The  constitutional  con¬ 
dition  that  tends  to  this  is  sufflcientl}'  characteristic  ;  but,  although  we 
may  recognize  its  existence,  and  speak  of  the  individual  possessing  such 
a  constitution  as  having  a  scrofulous  tendency  or  diathesis,  he  can 
scarcely  be  considered  to  labor  under  the  full^^-formed  disease,  unless 
some  of  the  above-mentioned  changes  have  taken  place  in  some  of  his 
tissues  or  organs. 

Scrofulous  Diathesis. — This  is  a  peculiar  constitutional  state  that  is 
often  erroneously  confounded  with  general  debility.  It  may,  and  often 
does,  coexist  with  this,  but  is  by  no  means  s^uioiy^mous  with  w^eakness 
of  constitution.  Debility  often  exists  without  an}’’  scrofulous  tendency 
or  taint,  more  particularty  in  individuals  of  the  nervous  temperament ; 
man}^  delicate  people,  though  weak,  being  perfectty  healthjq  and  showing 
no  disposition  to  this  peculiar  affection  ;  on  the  contraiy,  the  scrofulous 
constitution  is  often  conjoined  with  much  muscular  powder  and  mental 
activity.  But,  though  no  weakness  may  be  manifested  in  either  of  these 
respects,  scrofula  is  invariably  conjoined  with  debility  or  perversion  of 
the  nutritive  activity  of  the  bod}^  This  is  especially  manifested  in  cer¬ 
tain  tissues,  such  as  the  mucous  and  the  cutaneous  ;  and  in  those  organs, 


.  SCROFULOUS  DIATHESIS. 


675 


the  vitality  of  which  is  low,  as  the  lymphatic  glands,  the  bones,  and  the 
joints.  In  these,  scrofula  is  especially  apt  to  influence  the  products  of 
nutrition  and  of  inflammation,  more  particularly  during  the  early  periods 
of  life,  when  these  actions  are  most  energetic,  in  such  a  way  as  to  render 
its  existence  evident  to  the  Surgeon.  It  is  this  tendency  to  the  occur¬ 
rence  of  particular  diseases,  and  to  the  ingrafting  of  special  characters 
on  affections  of  certain  tissues,  that  may  be  considered  as  specially  indi¬ 
cative  of  the  existence  of  the  scrofulous  diathesis  ;  the  existence  of  which 
is,  moreover,  marked  by  the  presence  of  a  peculiar  temperament. 

The  Scrofulous  Temperament  assumes  two  distinct  forms,  the  fair  and 
the  dark,  and  each  of  these  presents  two  varieties,  the  fine  and  the  coarse. 
The  most  common  is  that  which  occurs  in  persons  with  fair,  soft,  and 
transparent  skin,  having  clear  blue  e3'es  with  large  pupils,  light  hair, 
tapering  fingers,  and  fine  white  teeth  ;  indeed,  whose  beauty  is  often 
great,  especiall}"  in  early  life,  being  dependent  rather  on  roundness  of 
outline  than  on  grace  of  form  ;  and  whose  growth  is  rapid  and  preco¬ 
cious.  In  these  individuals  the  affections  are  strong,  and  the  procreative 
power  considerable  ;  the  mental  activity  is  also  great,  and  is  usualty 
characterized  by  much  delicac}^  and  softness  of  feeling,  and  vivacity  of 
intellect.  Indeed,  it  w'ould  appear  in  such  persons  as  these,  that  the 
nutritive,  procreative,  and  mental  powers  are  rapidly  and  energetically" 
developed  in  early-  life,  but  become  proportionately  early  exhausted. 
In  another  variety  of  the  fair  scrofulous  temperament,  we  find  a  coarse 
skin,  short  and  rounded  features,  light  gray-  eyes,  crisp  and  curling 
sandy  hair,  a  short  and  somewhat  ungainly"  stature,  and  clubbed  fingers  ; 
but  not  uncommonly,  as  in  the  former  variety,  great  and  early  mental 
activity,  and  occasionally  much  muscular  strength. 

In  the  dark  form  of  the  scrofulous  temperament  we  usually  find  a 
somewhat  heavy,  sullen,  and  forbidding  appearance  ;  a  dark,  coarse, 
sallow,  or  greasy-looking  skin  ;  short,  thick,  and  harsh  curly  hair ;  a 
small  stature,  but  often  a  powerful  and  strong-limbed  frame,  with  a 
certain  degree  of  torpor  or  languor  of  the  mental  faculties,  though  the 
powers  of  the  intellect  are  sometimes  remarkably  developed.  The 
other  dark  strumous  temperament  is  characterized  by  clear  dark  eyes, 
fine  hair,  a  sallow  skin,  and  by  mental  and  physical  organization  that 
nearly  closely  resembles  the  first  described  variety  of  the  fair  strumous 
diathesis. 

In  all  these  varieties  of  temperament  the  digestive  organs  will  be  found 
to  be  weak  and  irritable.  This  condition,  which  I  believe  to  be  invariably" 
associated  with  struma,  and  the  importance  of  which  has  been  pointed 
out  by  Sir  James  Clark,  must  be  regarded  as  one  of  the  most  essential 
conditions  connected  with  scrofula,  and  as  tending  greatly  to  that 
impairment  of  nutrition  which  is  so  frequent  in  this  state.  This  gastric 
irritability  is  especially  characterized  by  the  tongue,  even  in  young 
children,  being  habitually  coated  towards  the  root  with  a  thick  white 
fur,  through  which  elongated  papillae  project,  constituting  the  “  pipped” 
or  “  strawberry”  tongue  ;  the  edges  and  tip,  as  well  as  the  lips,  Ijeing 
usually  of  a  bright  red  color.  This  state  of  the  tongue  is  aggravated 
by-  stimulants,  high  living,  and  habitual  use  of  purgatives.  In  the  fair' 
varieties  the  bowels  are  usually"  somewhat  loose,  but  in  the  dark  forms 
of  struma  there  is  a  torpid  condition  of  the  intestinal  canal.  In  all 
cases  the  action  of  the  heart  is  feeble,  the  blood  is  thin  and  watery" ; 
and  there  is  a  tendency  to  coldness,  and  often  to  clamminess  of  the 
extremities. 


676 


SCEOFULA  AND  TUBERCLE. 


Strumous  Inflammation. — One  of  the  most  marked  characteristics  of 
struma  is  certainly  the  peculiar  modification  that  infiammation  under¬ 
goes,  whether  we  regard  the  course  that  it  takes,  the  form  that  it 
assumes,  its  products,  or  its  seat.  The  course  of  inflammation  in 
strumous  subjects  is  always  slow,  feeble,  and  ill-developed,  the  more 
active  and  sthenic  conditions  being  rarely  met  with.  In  its  form  it  is 
usuall}'  congestive,  ulcerative,  or  suppurative  ;  and  in  its  products  it  is 
characterized  by  little  tendencj^  to  adhesion,  by  the  production  of  thin, 
blue,  weak,  and  undeveloped  cicatrices,  and  by  the  formation  of  thin, 
curdy  pus,  with  much  shreddy  corpuscular  lymph. 

The  seat  of  strumous  inflammation  varies  greatly  ;  and  peculiar  modi¬ 
fications  of  course,  form,  and  products  are  assumed,  according  to  the 
part  that  it  affects.  The  tissues  implicated  by  it  are  chiefly  the  skin 
and  mucous  membranes,  the  joints,  and  the  bones,  occasioning  a  great 
variety  of  special  diseases,  according  as  one  or  other  of  these  structures 
are  affected.  It  is  as  the  result  of,  or  in  connection  with,  these  local 
affections,  that  the  general  symptoms  of  struma  become  most  marked. 
Whatever  the  variety  of  temperament  may  be,  the  individual  usually 
emaciates,  becomes  sallow,  cachectic,  and  debilitated,  and  at  length  falls 
into  hectic  or  marasmus. 

When  affecting  the  Skin.,  scrofula  declares  itself  under  a  variety  of 
cutaneous  eruptions,  especially  the  different  forms  of  eczema  of  the  scalp, 
and  various  ulcers  on  the  surface,  usually  weak,  and  largely  granulating, 

with  considerable  swelling  the  sur¬ 
rounding  parts,  and  a  tendency  to  the 
formation  of  thin  blue  and  o:lazed  cica- 
trices  (Fig.  242).  The  integuments  of  the 
whole  of  the  limb  may  become  so  much 
diseased  in  this  way,  cedematous,  infil¬ 
trated,  and  covered  by  flabby  ulcers  and 
fistulse,  the  member  being  perhaps  double 
its  natural  size,  that  amputation  is  the 
sole  resource. 

The  Mucous  Membranes  are  commonly 
extensively  affected,  and  often  present  the 
earlier  forms  of  scrofulous  disease  in  child¬ 
hood  ;  this  is  more  especially  the  case  with 
those  of  the  e3'elids  and  nose.  The  conj  unc- 
tiva  becomes  chronically  inflamed,  perhaps 
with  ulceration  of  the  cornea.  The  mucous 
membrane  of  the  ej^elids  may  be  perma¬ 
nently  congested  and  irritated,  with  loss  of 
lashes,  constituting  the  different  forms  of  psorophthalmia.  The  mucous 
membrane  lining  the  nostrils  becomes  chronically  congested,  red,  and 
swollen,  giving  rise  to  habitual  sniffing  of  the  nose,  and  to  a  sensation  as 
of  a  constant  cold.  Occasionally  that  lining  the  antrum  becomes  irritated, 
and  may  then  occasion  an  enlargement  of  this  cavity,  or  the  discharge 
of  unhealthy  pus  into  the  nostrils.  The  tonsils  are  often  found  chroni¬ 
cally  enlarged  and  inglurated,  with  occasional  tendency  to  fresh  inflamma¬ 
tion  ;  and  the  larynx  may  become  the  seat  of  various  forms  of  aphonia, 
dependent  on  congestion  of  its  lining  membrane.  The  state  of  the 
gastro-intestinal  mucous  membrane  has  alread3’’  been  described  when 
speaking  of  the  state  of  the  tongue ;  and  that  of  the  genito-urinary 
organs  is  also  marked  by  a  tendency  to  debility  and  irritation,  indicated 


Fig.  243. 


TUBERCLE. 


677 


Fig.  243. 


Scrofulous  Disease  of  Arm  and 
Finger. 


by  discharges  from  the  urethra  induced  by  very  slight  exciting  causes, 
and  often  very  permanent.  The  occurrence  of  calculus  of  the  bladder, 
especially  in  children,  may  also  occasionally 
be  attributed  to  the  scrofulous  diathesis. 

Perhaps  the  most  important  local  diseases 
arising  under  the  influence  of  this  agency  are 
those  of  the  Bones  and  Joints.  The  bones  are 
liable  to  the  occurrence  of  various  forms  of 
caries  and  necrosis  (Fig.  243) ;  more  especially 
those  that  are  spongy  in  their  texture,  as  the 
short  bones  of  the  foot,  and  the  articular  ends 
of  long  bones.  The  joints  are  liable  to  that 
large  class  of  aflfections  that  are  commonly 
included  under  the  term  white  swelling^  which 
consists  of  thickening,  disorganization,  ulce¬ 
ration,  and  suppuration  of  the  synovial  mem¬ 
branes  and  cartilages. 

Lastly,  some  of  the  Glandular  Organs  are 
peculiarl}’^  prone  to  scrofulous  disease.  En¬ 
largement  of  the  lymphatic  glands,  more  par¬ 
ticularly  by  the  side  of  the  neck  and  under 
the  angles  of  the  jaw,  is  of  such  frequent  oc¬ 
currence,  and  is  usually  so  early  a  sign,  that 
the  Surgeon,  in  determining  whether  an  indi¬ 
vidual  is  scrofulous  or  not,  commonly  passes  his  hand  over  the  glands 
in  tliis  situation  in  order  to  ascertain  their  condition  and  size ;  these 
glandular  enlargements  are  especially  apt  to  run  into  unhealthy  and 
chronic  suppuration.  The  testes  and  the  mam  mm  are  occasionally 
affected;  but  other  glandular  structures,  though  sometimes  implicated, 
are  by  no  means  so  commonly  found  diseased  as  those  that  have  just 
been  mentioned. 

Tubercle. — The  occurrence  of  tubercle  indicates  a  far  greater  depar¬ 
ture  from  the  normal  nutrition  of  the  part  than  is  required  for  the  pro¬ 
duction  of  scrofula.  The  typical  constitutional  temperament  is  that 
described  at  page  674  as  the  first  scrofulous  variety,  but  every  degree 
will  be  found  to  exist  between  this  and  the  coarser  form.  Tubercle  more 
frequently  affects  the  serous  membranes  and  the  internal  organs,  espe¬ 
cially  the  areolar  tissue  entering  into  their  structure,  than  scrofula  does  ; 
whilst  the  skin  and  mucous  membranes,  which  are  commonly  attacked 
by  the  latter,  are  rarely  primarily  invaded  by  the  former. 

Tubercle,  though  sufficiently  well  marked  by  its  appearances  and  pro¬ 
gress,  cannot  be  looked  upon  as  a  specific  affection,  but  must  be  con¬ 
sidered  to  be  a  perverted  or  unhealthy  development  of  the  nutritive  ma¬ 
terials  destined  for  the  repair  of  the  body  and  the  restoration  of  the 
blood.  According  to  Simon,  it  consists  of  a  disease  of  the  lymph,  or 
nascent  blood.  It  is  a  “  dead  concretion,”  a  “fibriniform  product;  insus¬ 
ceptible  of  development.”  “  The  scrofulous  diathesis,”  says  Simon, 
“  consists  in  a  peculiarity  of  blood-development,  nnder  which  the  nascent 
blood  tends  to  molecular  death  by  superoxydation.  According  to  C.  J. 
B.  Williams,  “Tubercle  is  a  degraded  condition  of  the  nutritive  material 
from  which  the  old  textures  are  renewed,  and  the  new  ones  formed ;  and 
it  differs  from  fibrine  or  coagulable  lymph  not  in  kind,  but  in  degree  of 
vitality  and  capacity  of  organization.” 

It  must,  however,  be  viewed  in  the  light  of  a  new  formation  derived 
from  the  lymphatic  elements  of  the  connective  tissue  (Fig.  244),  and  it 


678 


SCEOFULA  AND  TUBERCLE. 


exhibits  a  constant  tendency  to  affect  the  lymphatic  sj^stem  in  every 
organ  which  it  invades.  It  is  essentially  a  lowly  organized  formation, 
tending  rapidly  to  disintegration  and  dissolution.  Recent  experiments 
have  confirmed  the  opinion  formerly  held,  that  it  has  not  a  specific 


Fig.  244. 


Diagram  from  Virchow,  of  Development  of  Tubercle  from  Connective  Tissue  in  the  Pleura,  showing 
Transition  from  Corpuscles  of  that  tissue  up  to  the  production  of  Tubercle  Granules.  The  cells  in 
the  middle  are  undergoing  fatty  degeneration.  300  Diameters. 


origin :  it  may  be  produced  in  the  lower  animals  by  the  introduction 
beneath  the  skin  of  irritating  or  putrid  animal  substances,  and  it  will 
very  readily  reproduce  itself,  both  locally  and  in  internal  organs,  when 
transferred  from  one  animal  to  another. 

Structure. — Tubercle  essentially  occurs  in  two  forms.  It  is  met  with 
as  semi-transparent  gray  granulations,  smooth,  and  cartilaginous  in  look, 
somewhat  hard,  closely  adherent,  and  accumulated  in  groups,  often  with 
a  good  deal  of  inflammatoiy  action  in  the  surrounding  tissues.  These 
gray  granulations,  usualh’’  about  the  size  of  a  small  pin’s  head,  appear 
to  consist  of  modified  exudation-matter.  They  have  a  tendency  to  run 
into  masses,  and  to  form  the  true  yellow  tubercle,  which  is  met  with  in 
opaque,  firm,  but  friable  concretions  of  a  dull  whitish,  or  yellowish  color, 
homogeneous  in  structure,  and  without  any  appearance  of  vascularity. 

The  microscopic  characters  of  tubercle  present  no  very  specific  ap¬ 
pearances.  The  gray  granulations  or  miliary  tubercle  consist  mainly 
of  a  firm,  homogeneous  stroma,  in  which  are  imbedded  a  number  of 
cells  and  nuclei.  These  cells  present  two  principal  varieties,  which 
measure  respectively  to  ^th  of  an  inch  in  diameter:  the  larger 

ones  contain  two  or  three  nuclei,  which  ma^"  sometimes  be  seen  in  the 
act  of  dividing;  the  smaller  ones  contain  only  a  single  nucleus.  Many 
free  nuclei,  oval  or  spindle-shaped,  also  exist. 

In  the  condition  called  crude  yellow  tubercle  multiple  cells  may  be 
found  at  the  circumference  of  the  mass,  whilst  single  nucleated  cells 
occupy  the  centre :  free  nuclei  are  scattered  abundantly  amongst  the 
cells.  Both  cells  and  nuclei  present  a  remarkably  shrivelled,  irregular, 
and  granular  appearance,  which  was  formerly  considered  as  their  great 
characteristic.  The  cells  measure  from  to  an  inch  in 

diameter.  In  the  softer  forms  of  yellow  tubercle  the  cells  are  more  dis¬ 
integrated,  and  drops  of  molecular  oil  and  much  granular  matter  are 
present.  The  fiuid  parts  may  subsequently  become  absorbed,  and  leave 
a  cheesy  or  cretaceous  mass.  Tubercle  must  often  be  recognized  rather 
by  its  negative  than  by  its  positive  characters — by  ascertaining  what  it 
is  not,  and  so,  by  a  process  of  exclusion,  arriving  at  its  true  nature.  It 
is  most  easily  confounded  with  pus,  from  which,  however,  it  may  be  dis¬ 
tinguished  by  its  possessing  a  solid  intercellular  substance. 


CAUSES  OF  SCROFULA  AND  TUBERCLE. 


679 


The  Progress  of  tubercle  is  most  commonly  to  disintegration  and 
liquefaction,  at  the  same  time  that  it  gives  rise,  by  its  irritation,  to  in¬ 
flammation  and  suppuration  in  the  surrounding  tissues ;  hence  it  com¬ 
monly  leads  to  abscesses,  the  pus  of  which  is  always  curdy  and  shreddy. 
In  some  cases  tubercle  may  become  indurated,  and  undergo  a  species  of 
calciflcation. 

Causes. — The  causes  of  scrofula  and  tubercle,  unless  these  be  of  a 
hereditary  character,  though  very  various  in  their  nature,  are  usually 
such  conditions  as  influence  injuriously  the  nutrition  of  the  body. 

The  Hereditary  Nature  of  both  scrofula  and  tubercle  is  well  known 
to  the  public  and  to  the  profession  ;  for,  although  the  disease  is  not 
commonly  connate,  yet  the  tendency  to  it  is,  and  the  characteristic 
nature  of  the  affection  often  manifests  itself  at  an  early  period,  notwith¬ 
standing  every  effort  to  prevent  its  development.  That  a  parent  may 
develop  a  tendenc}’’  to  malnutrition,  to  misdevelopment  of  the  blood, 
just  as  he  may  a  peculiar  feature  or  mental  condition,  is  undoubted.  It 
is  by  the  hereditary  transmission  of  peculiar  combinations  and  modifi¬ 
cations  of  action  in  the  organization  that  hereditary  diseases  develop 
themselves  at  certain  periods  in  the  life  of  the  offspring,  when  the 
injurious  results  of  the  morbid  actions  that  have  been  transmitted  have 
had  time  to  be  produced.  There  are  certain  conditions  which,  though 
not  scrofulous,  are  supposed  to  have  a  tendenc3^  to  develop  this  disease 
in  the  offspring  to  which  they  are  transmitted ;  thus  very  dyspeptic 
parents  commonly  have  strumous  children  ;  so,  also,  the  offspring  of 
very  old  or  very  young  people  often  exhibit  a  proneness  to  scrofulous  or 
tuberculous  affections.  The  influence  of  intermarriage  is  still  a  matter 
of  doubt,  but  I  believe  that  it  is  but  small ;  and  it  is  commonly  stated 
that  the  inhabitants  of  small  communities  who  intermarry  closely,  such 
as  those  of  the  Isles  of  Portland  and  of  Man,  are  not  more  liable  to 
scrofula  than  other  individuals. 

The  most  powerful  occasioning  cause  of  scrofula,  and  that  which  in 
most  civilized  countries  is  likewise  the  most  frequent,  is  malnutrition  and 
malassimilation  arising  from  an  habitual  disregard  of  hygienic  laws  ; 
either  from  want  of  food  or  the  administration  of  improper  food,  in  the 
poorer  classes;  or  from  overfeeding,  and  overstimulation  of  the  digestive 
organs,  amongst  the  children  of  the  wealthier  orders  of  society,  inducing 
chronic  irritation  of  the  mucous  membrane  of  the  stomach  and  inter¬ 
ference  with  the  digestive  powers,  and  consequently  with  nutrition.  The 
influence  of  food  that  is  innutritions  in  quality  or  insufficient  in  quantit3q 
has  been  shown  by  Philips,  in  his  excellent  Treatise  on  Scrofula^  to  be 
the  most  immediate  cause  of  this  disease;  and,  when  conjoined  with  the 
injurious  effects  of  a  confined  and  impure  atmosphere,  it  maj"  be  considered 
as  sufficient  to  occasion  the  disease  in  those  cases  in  which  no  predispo¬ 
sition  to  it  exists,  and  greatl^^  to  develop  any  hereditary  tendency  to  it 
in  the  system.  It  is  to  the  conjoined  influence  of  agencies  such  as  these, 
that  we  must  attribute  the  prevalence  of  scrofula  amongst  the  lower 
orders  both  of  town  and  of  rural  populations. 

Both  scrofula  and  tubercle  are  often  called  into  immediate  action  by 
the  debility  induced  by  previous  diseases,  such  as  measles,  scarlatina, 
hooping-cough,  etc.,  which  lead  to  overaction  of  the  lymphatic  system, 
resulting  in  an  active  h3q3erplasia  of  the  gland  elements.  The  former 
HSU  all}"  develops  itself  at  an  early  age,  though  seldom  before  the  child 
has  reached  its  second  3^ear.  It  is  most  commonly  about  the  period  of 
the  second  dentition  that  the  affection  declares  itself,  and  it  is  rare  to 
meet  with  it  for  the  first  time  after  the  ages  of  twent3''-five  or  thirty-five. 


680 


SCEOFULA  AND  TUBERCLE. 


According  to  Philips,  when  it  is  fatal,  it  usually  proves  so  before  the 
fifteenth  year;  60  to  70  per  cent,  of  the  deaths  occurring  before  this  age. 
Sex  does  not  appear  materially  to  influence  the  disease  ;  though,  accord¬ 
ing  to  the  same  authority,  the  deaths  of  males  from  scrofula  exceed  those 
of  the  females,  in  this  country,  by  24  per  cent.  These  numbers  may, 
however,  require  correction  if  we  are  to  regard  phthisis  as  an  affection 
dependent  upon  the  existence  of  either  of  these  conditions,  people  who 
are  scrofulous  in  early  life  often  becoming  the  subjects  of  that  form  of 
phthisis  now  called  scrofulous-pneumonia. 

Treatment. — This  should  rather  consist  in  endeavoring  to  prevent 
the  occurrence  of  full  manifestation  of  scrofula,  than  in  removing  it  when 
it  is  actually  existing.  Indeed  the  Preventive  Treatment  is  perhaps  of 
most  consequence,  and  by  proper  attention  to  it,  I  have  no  hesitation  in 
saying,  the  development  of  the  affection,  even  when  hereditary,  may  be 
stopped ;  and  the  child  of  strumous  parents,  presenting  perhaps  the 
features  indicative  of  the  diathesis,  may  pass  through  life  without  the 
disease  having  an  opportunity  of  declaring  itself.  In  order  to  accom¬ 
plish  this,  however,  the  preventive  plan  of  treatment  must  be  commenced 
early,  and  continued  uninterruptedly  for  a  considerable  time,  even  for 
years. 

The  preventive  treatment  of  scrofula  and  tubercle  may  be  said  in 
general  terms  to  consist  in  close  and  continuous  attention  to  h3^gienic 
rules.  The  diet  must  be  specially  attended  to ;  nourishing  food,  but  of 
the  lightest  quality,  being  given.  A  great  error  is  often  committed  in 
overloading  the  stomach  with  more  or  heavier  food  than  it  can  digest, 
under  the  impression  that  strong  food  is  necessary  to  give  the  patient 
strength.  In  consequence  of  this  error,  the  irritability  of  the  mucous 
membrane  is  kept  up,  nutrition  is  imperfectly  and  badly  performed,  the 
surplus  food  is  thrown  off  in  the  shape  of  lithates  or  other  products  of 
malassimilation,  and  health  and  strength,  which  are  the  results  of  per¬ 
fect  nutrition,  become  impaired  rather  than  improved.  The  use  of  stimu¬ 
lants,  whether  wine  or  beer,  should  be  very  sparing,  and  the  milder  and 
weaker  should  be  preferred  to  the  heavier  and  stronger  kinds  of  malt 
liquor;  the  bowels  must  be  kept  regular  with  the  simplest  aperients;  the 
clothing  should  be  warm,  and  must  cover  the  whole  of  the  surface ;  and 
the  patient  should,  if  possible,  be  kept  in  well-ventilated  rooms.  He 
should  be  allowed  sufficient  exercise  in  the  open  air,  not  carried  to  the 
point  of  fatigue,  and  should,  if  his  circumstances  will  permit,  have 
change  of  air  from  time  to  time,  alternating  a  sea  with  an  inland  climate. 
Bathing  also,  whether  in  sea  or  river,  with  the  habitual  use  of  the  tepid 
or  cold  sponge-bath,  and  friction  of  the  surface  with  horse-hair  gloves  or 
a  rough  towel,  so  as  to  keep  the  skin  in  healthy  action  and  its  cutaneous 
circulation  free,  should  be  regularly  practised. 

The  Curative  Treatment  shonldi  be  specially  directed,  like  the  preven¬ 
tive,  to  the  general  improvement  of  the  nutrition  and  through  it  to  the 
augmentation  of  the  constitutional  vigor  of  the  patient;  all  those  h^^gienic 
means  that  have  just  been  alluded  to  being  continuously  carried  out. 

The  more  strictly  medical  treatment  of  scrofula  consists  in  the  admin¬ 
istration  of  tonics  and  alteratives  with  the  view  of  improving  the  patient’s 
constitutional  powers.  Before  they  are  administered,  however,  it  is 
alwa^'S  necessar3'’  to  see  that  the  digestive  organs  are  in  a  healthy  condi¬ 
tion.  Scrofula  is  a  consequence  of  malnutrition ;  and  unless  we  see  that 
digestion,  the  first  stage  of  the  nutritive  process,  is  properly  accom¬ 
plished,  all  other  means  will  be  useless.  When  the  tongue  is  covered 
with  a  white,  thick,  creamy  fur,  and  has  elongated  papillae  and  red  edges, 


TREATMENT. 


6S1 


the  mucous  membrane  being  in  a  state  partl}^  of  irritation  and  partly  of 
debility,  neither  purgatives  nor  tonics  can  be  largely  administered ;  the 
former  irritating,  the  latter  overstimulating  the  morbidly  sensitive 
mucous  membrane.  In  these  circumstances  the  patient  should  be  con¬ 
fined  to  the  mildest  possible  diet,  which  must  principally  consist  of  milk, 
boiled  fish,  white  meats,  and  light  pudding,  no  stimulant  of  any  kind 
being  allowed  except  a  small  quantity  of  claret  or  bitter  beer ;  and, 
unless  the  patient  have  been  accustomed  to  the  use  of  stimulants,  these 
even  had  better  be  dispensed  with.  Small  doses  of  mercury  with  chalk, 
of  soda  and  rhubarb,  should  be  occasionally  administered  at  bedtime, 
with  some  of  the  compound  decoction  of  aloes  on  the  following  morning, 
and  a  few  grains  of  the  carbonate  of  soda  or  of  potass  may  be  given 
twice  or  thrice  a  day  in  some  light  bitter  infusion,  as  of  cascarilla  or 
calumba.  In  many  cases  of  strumous  disease,  more  especially  those 
affecting  the  joints  and  bones,  the  liver  will  be  found  to  be  enlarged  and 
sluggish  in  its  action,  the  patient  every  now  and  then  becoming  bilious, 
sallow,  and  jaundiced;  in  these  circumstances,  small  doses  of  blue  pill, 
carried  off  with  the  compound  decoction  of  aloes  or  a  rhubarb  draught, 
will  be  found  necessary  from  time  to  time.  When  all  gastric  irritation 
has  been  removed  in  this  way,  or  if  it  have  not  existed  in  the  usual 
marked  degree  from  the  first,  the  patient  being  pale  and  flabby,  with  a 
weakened  condition  of  the  pulse,  of  the  skin,  and  of  the  mucous  surface, 
then  tonics  may  be  administered,  and  the  more  specific  treatment  adopted. 

The  great  remedies  which  are  employed  with  the  view  of  removing 
scrofula  and  curing  the  secondary  affections  which  it  induces,  are  iron, 
iodine,  the  preparations  of  potass,  and  cod-liver  oil.  These  are  all 
extremely  useful,  either  singly  or  conjoined,  as  they  serve  to  carry’ out 
distinct  indications  in  the  management  of  this  affection. 

Iron  is  most  useful  in  improving  the  nutrition  of  pale  flabby  anaemic 
subjects,  increasing  markedly  the  quantity  and  quality  of  blood  in  the 
system.  The  best  preparations  for  children  are,  I  think,  the  vinum  ferri 
and  the  iodide.  In  older  persons  the  tincture  of  the  sesquichloride  and 
some  of  the  forms  of  the  citrate  or  the  phosphate  of  iron,  appear  to 
be  most  serviceable  ;  in  other  cases,  again,  the  natural  chalybeate  waters 
will  be  found  to  agree  best. 

Iodine  is  especiall}’  valuable  in  promoting  the  absorption  of  effused 
plastic  matters,  and  in  lessening  the  morbid  hypertrophies  which  so  com¬ 
monly  take  place  in  scrofula.  The  preparation  usually  emplo3"ed  is  the 
iodide  of  potassium.-  In  order  that  this  may  produce  its  full  effects,  it 
should  be  given  as  freely  as  the  patient  will  bear  it,  continued  for  a  con¬ 
siderable  length  of  time,  and  especially  administered  in  combination 
with  other  preparations  of  potass.  With  the  view  of  preventing  it  from 
irritating  the  stomach,  it  should  be  given  in  a  considerable  quantity"  of 
some  bland  fluid.  Its  combination  with  the  otlier  salts  renders  it  more 
efficacious  in  removing  strumous  enlargements  and  deposits  of  aplastic 
and  tuberculous  matter.  For  this  purpose  I  have  found  the  following 
form  extremely  useful  for  adults,  the  dose  being  proportionately'  dimin¬ 
ished  in  the  case  of  children :  R  Potassii  iodidi,  Pottassse  chloratis, 
aa  5jv  Pottassse  bicarbonatis,  3iU*  Divide  into  twelve  powders,  of 
which  one  is  to  be  taken  night  and  morning  in  half  a  pint  of  warm  milk. 
In  other  cases,  the  liquor  potassse,  Brandish’s  alkaline  solution,  or  lime- 
water  given  freely  in  milk,  are  serviceable ;  but  I  prefer  the  above  pre¬ 
scription. 

Cod-liver  oil^  which  ma}^  be  looked  upon  rather  as  an  article  of  diet 
than  as  a  medicine,  is  of  essential  utility  in  improving  the  nutrition  of 


682 


SCROFULA  AND  TUBERCLE. 


the  body  in  cachectic  and  emaciated  states  of  the  system,  more  particu¬ 
larly  in  growing  children,  or  in  individuals  who  are  suffering  from  wasting 
effects  of  strumous  suppuration  ;  it  not  only  fattens  but  strengthens  the 
system,  increasing  decidedly  the  muscular  power  and  the  quantity  of 
red  corpuscles  in  the  blood.  It  may  often  very  advantageously  be 
administered  in  combination  with  the  iodides  of  potassium  or  of  iron, 
and  given  after  meals. 

Of  the  other  tonic  remedies  which  may  be  emplo3^ed  in  this  affection, 
such  as  the  preparations  of  hark  and  of  sarsaparHlla^  I  need  sa^"  nothing 
beyond  that  they  may  often  be  usefull}’-  administered  in  fulfilling  ordi- 
naiy  therapeutic  indications.  Ringer  has  latel^^  recommended  the  sul¬ 
phide  of  calcium  as  extremely  valuable  in  scrofulous  and  tuberculous 
glands,  and  in  chronic  strumous  sores  and  abscesses.  He  uses  it  in  a 
solution  which  has  much  the  strength  of  Harrogate  Waters.  Thus,  he 
directs  a  grain  of  the  sulphide  of  calcium  to  be  dissolved  in  half  a  pint 
of  water,  and  of  this  a  teaspoonful  is  taken  every  hour.  Under  its  influ¬ 
ence,  the  glands,  it  is  said,  either  return  to  the  normal  state  or  hasten  on 
to  suppuration,  and  chronic  abscesses  either  dry  up  or  are  as  speedily 
brought  forward  and  their  contents  discharged,  a  healthy  healing  sore 
being  left. 

The  Local  Treamcnt  of  scrofula  consists  in  a  great  measure  in  the 
ordinary  local  management  of  chronic  inflammation,  modified  according 
to  the  seat  and  particular  nature  of  the  affection.  Much  of  the  local 
treatment,  however,  especially  in  the  more  advanced  stages,  consists  in 
removing  the  efiects  of  the  disease  in  the  shape  of  aplastic  deposits,  false 
h3q:>ertrophies,  and  general  enlargement  and  thickening  of  parts.  This 
may  usuall}-  be  done  by  the  application  of  lotions  containing  the  iodide 
of  potassium,  or  the  carbonate  of  potass,  applied  by  means  of  lint 
with  oiled  silk ;  a  drachm  of  each  of  the  salts,  with  an  ounce  of  spirits 
of  wine  to  eleven  ounces  of  water,  makes  an  excellent  application,  which 
appears  to  disolve  aww  the  fibrinous  and  plastic  deposits  common  in 
this  disease.  In  many  cases,  frictions  with  the  iodide  of  lead  ointment, 
or  pressure  by  means  of  strapping  and  bandages,  will  be  found  the  most 
serviceable  means  that  the  Surgeon  can  adopt.  When  matter  forms,  it 
should  be  let  out  in  accordance  with  the  rules  laid  down  in  treating  of 
the  more  clironic  forms  of  abscess.  In  these  cases,  the  injection  of  the 
sac  of  the  abscess  with  a  solution  of  iodine  will  be  found  very  useful. 
Operations  in  Scrofulous  and  Tuberculous  Cases. — In  cases 
of  scrofulous  diseases  of  the  soft  parts,  the  bones,  or  the  joints,  the 
question  of  the  propriety  of  operating,  whether  this  be  for  the  excision 
of  a  gland,  the  resection  of  a  joint  or  bone,  or  the  amputation  of  a  limb, 
has  often  been  discussed.  In  these  cases,  operations  should  not,  I  think, 
be  undertaken  too  hastily,  too  earl}^  in  the  disease,  or  especially  in  very 
young  subjects.  The  affection  being  constitutional,  it  will  often  be 
found  as  the  general  health  of  the  patient  is  improved  by  proper  treat¬ 
ment,  that  local  mischief,  which  at  first  appeared  very  intractable, 
gradually’  assumes  a  more  circumscribed  and  liealthy  form,  and,  in  fact, 
to  a  great  extent  undergoes  spontaneous  cure  by  the  restoration  of  the 
healthy  action  in  the  parts.  This  we  especially  find  to  be  the  case  in 
young  children,  in  whom  veiy  extensive  disease  of  the  bones  and  joints 
ma}^  often  be  recovered  from,  without  the  necessit}’’  of  anj^  serious  sur¬ 
gical  interference.  Should  any  operation  be  undertaken,  it  is  desirable 
not  to  have  recourse  to  it  whilst  the  disease  is  actively  spreading.  In 
these  circumstances,  it  is  not  only  probable  that  suppurative  inflam¬ 
mation  of  an  unhealth^’^  kind  may  be  set  up  in  the  wound  itself,  but  that 


VENEREAL  DISEASES. 


683 


disease  of  the  soft  parts  or  bones  may  recur  in  the  cicatrix  of  the  original 
wound,  or  that  the  corresponding  parts  on  the  opposite  side  of  the 
body  ma}^  become  similarly  affected  in  very  chronic  cases  of  scrofulous 
diseases  of  bones  and  joints.  I  have  several  times  observed,  after  ex¬ 
cision  of  the  elbow,  the  knee,  or  the  bones  of  the  foot  and  wrist,  that  the 
morbid  action  has  returned  in  the  contiguous  soft  parts  to  such  an  extent 
as  to  render  a  second  operation  necessary,  although  the  bones  were  not 
implicated ;  the  tissues  in  the  neighborhood  of  the  cicatrix  becoming 
swollen,  spongy,  and  infiltrated  with  a  quantity  of  gelatinous  semi¬ 
transparent  plastic  matter,  running  into  unhealthy  suppuration,  with 
fistulous  tracts  leading  through  it  that  could  not  be  brought  to  heal. 
In  some  cases  even  of  simple  strumous  disease  of  the  integuments  of 
the  arm,  leg  or  foot,  attended  with  great  and  irregular  deposition  of 
plastic  matter,  and  chronic  and  intractable  ulceration,  amputation  of 
the  limb  is  the  only  course  left  to  the  Surgeon.  When  strumous  suppu¬ 
ration  leads  to  hectic,  the  patient  will  speedily  sink  unless  the  diseased 
structures  be  removed. 


CHAPTER  XXXYI. 

VENEREAL  DISEASES. 

The  term  Venereal  Disease  is  used  to  denote  those  affections  which 
arise  primarily  from  sexual  intercourse.  It  was,  until  latel3q  held  to 
include  two  distinct  specific  diseases — Syphilis  and  Gonorrhoea.  The 
special  researches  of  Surgeons  in  this  countiy  and  on  the  continent 
have,  however,  in  late  3'ears,  apparently  established  the  fact,  that  in  the 
term  Syphilis  there  have  been  included  two  distinct  affections,  both 
communicable  by  contagion  during  intercourse,  but  differing  in  their 
characters,  and  especially  in  this,  that  the  one  is  a  purel3^  local  affection, 
while  the  other  not  only  produces  local  effects,  but,  by  the  introduction 
of  a  specific  poison  into  the  S3"stem,  infects  the  general  constitution  of 
the  person  to  whom  it  is  communicated.  To  the  purely-  local  disease 
the  term  Local  Contagious  Ulcer  or  Chancre  ma3-  be  applied;  the  word 
S3q)hilis  being  restricted  to  the  constitutional  affection. 

Hunter  and  his  followers  supposed  that  all  the  specific  diseases  arising 
from  sexual  intercourse  originated  from  one  and  the  same  poison.  But 
this  doctrine  has  been  proved  to  be  erroneous ;  for  not  01113’'  are  the 
local  appearances  and  constitutional  effects  of  these  diseases  widely 
different,  but  Ricord  has  shown,  in  the  most  conclusive  manner,  that 
gonorrhoeal  matter,  when  inoculated  on  the  skin  or  mucous  membrane, 
never  produces  a  chancre;  and  that,  on  the  other  hand,  chancrous  pus 
can  never  be  made  to  produce  gonorrhoea.  Each  of  the  diseases — Local 
Contagious  Chancre,  S3’'philis,  and  Gonorrhoea — propagates  itself,  and 
no  other.  Two  of  these  diseases  may,  however,  coexist  in  the  same 
person.  Thus,  we  shall  have  occasion  to  notice  the  coincidence,  in  some 
cases,  of  the  local  chancre  with  the  phenomena  of  constitutional  syphilis. 
Again,  Ricord  has  pointed  out,  that  a  woman  ma3’  at  the  same  time  be 
affected  b3-  gonorrhoea  and  by  chancres  on  the  uterus;  and  this  proba¬ 
bly  explains  those  cases  in  which,  after  connection  with  the  same  woman, 
different  men  have  contracted  different  forms  of  disease,  or  even  both 

I 


I 


684 


VENEREAL  DISEASES. 


affections.  In  this  chapter,  Tve  shall  describe — 1,  the  Local  Contagious 
Ulcer  or  Chancre  ;  2,  Syphilis,  or  Constitutional  Syphilis  ;  reserving  the 
consideration  of  Gionorrhoea  till  we  speak  of  Diseases  of  the  ITrinary 
Organs. 


L— LOCAL  CONTAGIOUS  ULCER  OR  CHANCRE. 

The  Local  Contagious  Ulcer  or  Chancre  is  a  sore  of  special  form  and 
appearance,  characteristic  of  the  nature  of  the  disease.  It  may  occur  on 
the  cutaneous,  the  muco-cutaneous,  and  mucous  surfaces,  most  com- 
monl}’  on  the  latter,  on  account  partly  of  their  greater  exposure  to 
contagion,  but  chiefly  from  their  being  less  perfectly  protected  by  epi¬ 
dermis.  Chancres  present  much  variet}^  as  to  their  appearance  and  to 
the  course  which  they  pursue :  so  great  indeed  are  the  varieties,  that 
they  have  been  looked  upon  by  some  Surgeons  as  affording  evidence 
of  distinct  diseases  proceeding  from  different  poisons.  This  doctrine, 
however,  is  entirelj"  erroneous ;  the  varieties  in  their  appearance  depend 
on  seat,  constitution,  and  other  accidental  circumstances.  A  chancre, 
then,  is  a  specific  venereal  sore  or  ulcer,  originating  invariably  from 
contagion,  and  capable  of  propagation  to  other  parts  of  the  same  or  of 
different  individuals  by  inoculation.  Like  all  other  ulcers,  a  chancre 
presents  two  distinct  periods ;  the  first,  in  which  it  is  either  spreading 
or  stationary,  in  which  alone  it  is  specific,  and  which  may  be  of  almost 
indefinite  duration;  and  the  second,  in  which  it  has  commenced  to 
granulate,  and  a  process  of  repair  is  set  up  in  it.^ 

Specific  Nature. — Ricord  has  made  the  important  observation  that, 
if  the  pus  from  a  chancre,  during  its  first  period,  be  inoculated  into  an}' 
part  of  the  surface  of  the  bod}',  it  will  invariably  produce  another  specific 
venereal  sore  or  chancre ;  and  that  no  pus  that  is  not  chancrous  can, 
under  any  circumstances,  occasion  the  specific  venereal  ulcer.  This 
inoculable  ulcer  is  always  in  its  effects  a  local  disease,  being  confined  to 
a  specific  sore;  of  which  the  furthest  complications  are  repetition  of  the 
sore  wherever  its  discharge  invades  an  unprotected  surface,  and  the 
occasional  irritation  of  the  neighboring  lymphatic  glands  to  inflam¬ 
mation  and  abscess. 

Origin  and  Progress. — A  chancre  is  necessarily  generally  contracted 
in  impure  sexual  intercourse  with  a  person  already  contaminated  by  the 
disease,  by  the  direct  contact  of  the  healthy  with  a  previously  diseased 
surface.  When  a  chancre  is  caught  in  connection,  it  usually  commences 
with  a  small  excoriation,  which  appears  to  have  been  directly  inoculated 
with  the  specific  poison.  In  other  cases,  though  more  rarely,  it  may 
be  seen  at  first  in  the  shape  of  a  small  pointed  pustule,  which  speedily 
breaks,  leaving  an  ulcer  of  a  specific  character  in  its  site.  Very  gener¬ 
ally,  however,  this  pustule  escapes  observation,  and  the  disease  is  pre¬ 
sented  in  the  first  instance  as  an  ulcer.  The  chancrous  ulcer,  wdiatever 
form  it  assumes,  seldom  makes  its  appearance  until  a  few  days  (five  or 
six)  after  connection.  In  some  cases,  however,  I  have  observed  it, 
evidently  from  the  infection  of  a  fissure  or  crack,  on  the  day  following 
impure  intercourse ;  and  occasionally,  in  rare  instances,  its  appearance 
may  be  delayed  a  few  days  longer  than  that  time  which  has  been  men¬ 
tioned. 

’  The  terra  Chancre  is  also  applied  to  the  ulcer  which  is  the  primary  manifes¬ 
tation  of  constitutional  syphilis.  This  chancre,  which  presents  distinctive  charac¬ 
ters,  will  be  found  described  at  page  698. 


PROGEESS  AND  VARIETIES  OF  CHANCRE. 


685 


Chancres  are  occasional!}^  contracted  in  various  irregular  ways.  Thus 
they  may  occur  on  the  fingers  of  Surgeons  or  accoucheurs  from  dressing 
venereal  sores,  or  from  attending  diseased  women  during  labor.  In  these 
instances,  however,  the  consequences  of  contagion  are  nearly  always  of 
another  kind  ;  namely,  the  inoculation  of  constitutional  syphilis,  not  the 
merely  local  ulcer.  In  other  cases,  the  disorder  is  contracted  from  the 
contact  of  filthy  clothes  or  dirty  utensils  with  the  person  ;  and  not  un¬ 
commonly,  it  is  said,  chancres  are  contracted  at  public  water-closets. 
Although  the  latter  mode  of  infection  is  not  impossible,  it  should  be 
received  with  doubt,  as  it  is  an  explanation  not  uncommonly  adopted  by 
those  who  desire  to  account  for  the  consequences  of  an  act  of  immorality, 
in  a  way  that  does  not  expose  them  to  reproof. 

Whatever  be  the  appearances  presented  by  a  chancre,  there  can  no 
longer  be  any  doubt  that  the  disease  arises  from  one  kind  of  virus  only; 
the  modifications  in  the  sore  depending  on  its  situation,  on  the  constitu¬ 
tion  of  the  patient,  and  occasionally  on  that  of  the  individual  who  com¬ 
municates  the  infection.  That  this  is  so,  is  evident  from  the  facts  that 
every  chancre,  when  inoculated,  reverts  to  one  typical  form ;  and  that, 
however  much  chancres  may  ultimately  differ,  they  all  present  the  same 
characters  during  their  early  stages. 

The  progress  of  a  chancre  that  has  been  artificially  inoculated  on  any 
part  of  the  cutaneous  surface  is  as  follows,  and  its  study  will  serve  to 
elucidate  what  takes  place  in  other  circumstances.  During  the  first 
twenty-four  hours  after  the  introduction  of  the  specific  pus  into  the  skin 
on  the  point  of  a  lancet,  we  find  that  some  inflammation  is  set  up  around 
the  puncture,  which  becomes  hot,  red,  and  itchy.  About  the  third  or 
fourth  day,  a  pointed  pustule  is  produced,  which  is  at  first  deep-set,  but 
becomes  on  the  following  day  more  superficial,  with  some  depression  in 
the  centre,  resembling  rather  closely  a  smallpox  pustule;  on  close  ex¬ 
amination,  this  will  be  found  not  to  be  a  true  pustule,  but  rather  a  mass 
of  epithelial  scales  and  pus  not  included  in  a  distinct  wall.  On  the  fifth 
day,  it  has  become  hard  at  the  base,  apparently  from  the  infiltration  of 
plastic  matter ;  and  on  the  sixth  it  has  usually  dried,  forming  a  small 
round  scab,  and  leaving  an  ulcer  which  presents  the  typical  characters 
of  a  true  chancre,  being  circular  and  depressed,  with  a  foul  grayish  sur¬ 
face  which  cannot  be  cleansed,  sharp-cut  edges,  a  hard  base,  and  an  angry- 
looking  red  areola  around  it.  This  is  the  typical  chancre,  and  these  are 
the  appearances  that  every  true  venereal  non-syphilitic  sore  on  the  skin 
will  present  about  the  fifth  or  sixth  day  after  inoculation  ;  from  this  time 
it  may  diverge  more  or  less  completely  from  these  characters,  but  will 
yet,  if  inoculated  at  any  time  during  the  poisonous  stage,  produce  an 
ulcer  that  will  run  the  specific  course  up  to  the  same  period,  after  which 
it  may  in  its  turn  again  deviate  into  one  or  other  of  the  unusual  forms 
that  chancres  occasionally  assume. 

Varieties. — These  have  been  described  under  various  denominations 
by  the  numerous  writers  on  these  affections.  The  following  classifica¬ 
tion  will  include  them  all:  1,  the  Simple  or  Soft  Chancre,  or  Chancrous 
Excoriation;  2,  the  Phagedmnic  Chancre  ;  and  3,  the  Sloughing  Chancre. 
As  H.  Lee  has  observed,  each  of  these  varieties  of  chancres  is  associated 
with  a  particular  variety  of  inflammatory  action.  Thus  the  soft  is  the 
suppurative  form ;  the  phageddenic,  the  ulcerative ;  and  the  sloughing^ 
the  gangrenous.  The  particular  form  of  the  sore  is  in  each  case  deter¬ 
mined  by  its  situation,  and  the  constitution  of  the  patient  or  that  of  the 
individidual  furnishing  the  contagion. 


686 


TEXEKEAL  DISEASES. 


1.  Simple  or  Soft  Chancre^  or  Chancrous  Excoriation,  is  certain!}'  that 
form  of  the  disease  which  is  most  commonly  met  with  in  London  at 
present,  from  its  excessively  contagious  character.  It  consists  of  one  or 
more  small  sores,  of  a  veiy  shallow  character,  resembling  rather  an  abra¬ 
sion,  with  sharp-cut  edges,  somewhat  circular  in  shape,  and  having  a 
tawn}'  gra3'ish  or  3'ellowish  surface,  with  a  narrow  red  areola  around  the 
edge  ;  in  man}’  cases  attended  with  much  heat  and  itching.  These  sores 
are  usuall}'  seated  on  the  cleft  under  the  corona  glandis,  or  about  the 
glans,  the  whole  of  which  ina}'"  be  studded  b}’  them.  In  fact,  one  pecu- 
liarit}^  of  this  chancre  is  its  tendenc3’to  multiplication  on  the  contiguous 
structures.  In  other  cases,  the  sores  invade  the  fraenum,  which  may  be 
perforated  ;  or  the}'  may  occupy  the  mucous  surface  of  the  prepuce.  In 
no  cases  are  they  indurated. 

The  excoriated  chancres  not  imfrequently  present  somewhat  varying 
appearances.  In  some  cases  their  surface  becomes  covered  with  large 
fungous  granulations,  hence  termed  fungating  sores.  In  other  instances 
they  are  truly  irritable,  becoming  exceedingly  sensitive,  with  a  tendency 
to  spread,  and  having  a  dusky  red  areola  around  them.  These  chancres 
are  very  frequently  attended  by  much  general  inflammation  of  the  penis; 
the  organ  being  swollen,  red,  and  semi-transparent,  from  subcutaneous 
oedema,  and  usually  in  a  state  of  phimosis,  with  much  purulent  secretion 
between  the  prepuce  and  glans. 

2.  Pliagedsenic  Chancre  is  characterized  by  a  tendency  to  erosion, 
with  much  destruction  of  the  parts  that  it  invades.  It  may  assume  the 
phagedmnic  character  from  the  very  first,  or  this  may  be  set  up  in  one 
of  the  other  varieties  of  chancre  at  some  period  of  their  course.  The 
progress  of  this  phagedaenic  or  eroding  chancre  is  usually  somewhat 
slow,  but  continuous;  it  commonly  afi*ects  the  glans,  more  especially  in 
the  neighborhood  of  the  frmuum  or  urethra,  destroying  a  considerable 
portion  of  the  organ  in  this  situation.  Wallace  has  divided  this  form  of 
chancre  into  three  varieties  ;  that  luithout  sloughy  that  with  white  sloughy 
and  that  icith  black  slough.  Each  of  these  varieties,  again,  may  be  of  a 
simple.,  an  inflamed.,  or  an  irritable  character.  This  classification  ap¬ 
pears  to  me  to  be  an  useful  and  practical  one,  and  I  accordingly  adopt  it. 

The  phagedwnic  chancre  icithout  slough  is  a  truly  eroding  ulcer, 
spreading  with  sharply  cut  edges,  attended  by  some  slight  inflammatory 
action;  and  with  much  activity  of  progress;  it  is  commonly  observed 
about  the  frmnum  and  under  part  of  the  glans,  and  very  frequently 
hollows  out  and  destroys  the  organ  in  this  situation  to  a  considerable 
extent. 

In  the  phagedaenic  chancre  with  ichite  slough.,  we  find  an  irregular  ero¬ 
ding  ulcer,  with  a  thin  margin  of  white  slough  situated  at  the  junction 
of  the  dead  and  living  structures ;  that  which  covers  the  surface  of  the 
sore  having  usually  become  darkened  by  exposure  to  air,  to  dressings, 
and  to  secretions. 

The  phagedaenic  chancre  ivith  black  slough  differs  but  little  from  the 
last,  except  in  the  color  of  the  slough,  which* may  be  in  a  great  measure 
accidental,  and  in  its  tendency  to  induration,  and  to  somewhat  rapid 
extension ;  it  must  not  be  confounded  w’ith  the  next  form  of  chancre, 
which  presents  many  points  of  difference.  All  these  varieties  of  phage¬ 
daenic  chancre  may  be  inflamed,  being  attended  with  much  heat,  redness, 
and  swelling,  increase  of  discharge,  and  rapidity  of  action ;  or  they  may 
be  irritable,  occurring  in  cachectic  individuals,  when  they  are  accompa¬ 
nied  by  much  pain,  and  usually  a  good  deal  of  constitutional  disturb¬ 
ance  of  a  nervous  and  irritative  type. 


SITUATION  OF  CHANCRE. 


687 


3.  Sloughing  Chancre^  or  Garigrenous  Phagedaena,  is  a  combination 
of  rapidly  spreading  and  destructive  gangrene  with  the  venereal  poison, 
and  may  be  looked  upon  as  a  gangrenous  inflammation  of  a  venereal 
sore. 

The  gangrene  is  usually  the  consequence  of  the  conflnement  of  the 
venereal  pus  under  an  elongated  prepuce,  in  a  person  of  inflammatory 
and  irritable  constitution,  in  whom  the  loose  areolar  tissue  of  the  genital 
organs  readily  takes  on  sloughing  action  when  inflamed.  It  usually 
affects  the  upper  surface  of  the  prepuce.  The  parts  becoming  immensely 
swollen,  red,  and  somewhat  brawny,  and  the  prepuce  being  in  a  state 
of  complete  and  permanent  phimosis,  a  dusky  black-looking  spot  soon 
makes  its  appearance  on  one  side  of  the  organ  ;  this  rapidly  extends, 
giving  rise  to  thick,  black,  soft,  and  pultaceous  sloughs,  destroying  per¬ 
haps  the  whole  of  the  prepuce,  and  exposing  and  implicating  the  glans 
to  a  great  extent,  accompanied  sometimes  by  copious  hemorrhage  from 
the  dorsal  artery  of  the  penis  on  the  separation  of  the  sloughs,  and  by 
denudation  of  the  corpora  cavernosa.  In  other  cases,  the  prepuce 
sloughs  on  one  side  only;  around  aperture  forming  in  it,  through  which 
the  glans  projects,  whilst  the  swollen  and  inflamed  extremity  of  the 
prepuce  hangs  down  behind  it,  giving  the  organ  a  very  remarkable,  and 
at  first  sight  somewhat  puzzling,  appearance.  After  the  separation  of 
the  sloughs,  granulations  rapidly  spring  up,  the  sore  loses  its  specific 
character,  and  cicatrization  advances  with  rapidity. 

Situation. — As  chancres  almost  invariably  result  from  connection 
with  persons  suffering  from  sores  of  similar  nature,  they  commonl}’’ 
occur  on  the  genital  organs.  In  the  male  they  maj^  be  met  with  in  any 
part  of  these ;  their  characters  vary  somewhat,  however,  according  to 
the  situation  in  which  they  occur.  They  are  by  far  most  commonly 
seated  in  the  angle  formed  between  the  glans  and  the  prepuce  ;  they 
then  appear  most  frequently  at  the  orifice  or  on  the  inner  surface  of  the 
prepuce,  next  on  the  frsenum,  then  on  the  glans,  and  lastly  at  the 
orifice  of  the  urethra,  or  on  the  skin  of  the  body  of  the  penis.  Those 
about  the  fraenum  are  often  sloughy  and  irritable,  have  a  great  ten¬ 
dency  to  perforate  or  destroy  this  membrane,  and  are  more  frequently 
followed  by  hemorrhage  or  bubo  than  any  of  the  other  varieties  of  the 
disease. 

The  Urethral  Chancre  is  usually  situated  just  within  the  orifice  of 
the  canal,  and  may  be  5een  on  pressing  open  its  lips,  in  the  form  of  a 
small  sloughy  sore,  which  occasionally  creeps  out  upon  the  glans. 
Sometimes  it  is  more  deeply  seated,  so  as  to  be  out  of  sight ;  when  this 
is  the  case,  a  thick,  tenacious,  sloughy  and  bloody  discharge  appears  in 
small  quantities  from  the  urethra ;  at  a  little  distance  up  the  canal  there 
will  usually  be  felt,  on  grasping  the  organ  between  the  fingers,  a  circum¬ 
scribed  indurated  spot,  which  is  somewhat  painful  on  pressure  and  after 
micturition.  The  chancres  have  been  found  b^"  Ricord  to  extend  along 
the  whole  of  the  urethra,  even  to  the  bladder ;  and  it  is  their  presence 
in  this  canal  that  formerly  led  to  the  supposition  of  the  identity  of 
sjq^hilis  and  gonorrhoea,  an  error  which  has  been  disproved  by  the  test 
of  inoculation ;  the  discharge  from  urethral  chancre  producing  the  typi¬ 
cal  sore,  that  from  gonorrhoea  giving  no  result  when  introduced  under 
the  skin.  The  existence  of  chancre  within  the  urethra  may  be  sus¬ 
pected  if  the  urethral  discharge  be  small  in  quantit}^  and  somewhat 
dark  colored,  ichorous,  and  sloughy  in  appearance.  The  chancre  may 
be  detected  by  everting  the  edges  of  the  urethra,  or,  if  situated  too 


688 


VENEREAL  DISEASES. 


high  up  the  canal  to  be  seen,  by  being  felt  hard  and  nodulated  through 
its  coats. 

Chancres  may  also  form  on  other  parts  where  they  have  been  acci- 
dentall}^  or  purposely  inoculated.  Thus  I  saw  many  years  ago  (1839)  in 
Ricord’s  wards,  a  man,  laboring  under  eczema  of  the  legs,  in  whom  the 
cutaneous  disease  had  been  converted  into  a  series  of  immense  chancres 
by  accidental  inoculation  from  a  sore  on  the  penis. 

In  women,  chancres  are  usuallj-  situated  on  the  external  organs  of 
generation,  most  usuall}^  just  inside  the  fourchette  or  labia  minora,  very 
rarely  indeed  on  the  lining  membrane  of  the  vagina,  but  sometimes  on 
the  cervix  or  os  uteri;  hence  it  is  impossible  ever  to  pronounce  a  woman 
free  from  chancre  without  examining  these  parts  by  means  of  the  specu¬ 
lum.  When  situated  upon  the  external  organs,  they  are  not  unfre- 
quently  concealed  between  the  rugae,  or  in  nooks  and  corners  of  the 
mucous  membrane.  In  these  cases,  their  presence  may  sometimes  be 
detected  by  the  labia  being  swollen  and  oedematous  from  the  irritation 
produced  by  them. 

Diagnosis. — The  diagnosis  of  chancre  is  usually  sufficiently  easy, 
the  peculiar  character  of  the  sore  enabling  the  Surgeon  to  recognize  it 
in  all  its  forms.  In  some  instances,  however,  it  is  by  no  means  easy  to 
say  positively  whether  an  ulcer  on  the  penis  be  or  be  not  chancrous.  It 
is  especially  difficult  to  distinguish  some  forms  of  excoriated  chancres 
from  herpes  or  aphthie  on  the  prepuce  or  glans,  or  from  those  slight  ex¬ 
coriations  that  many  men  habitually  contract  after  a  somewhat  impure 
connection  ;  so,  also,  the  wound  resulting  from  a  ruptured  fraenum  often 
Ijresents  a  suspicious  appearance.  In  these  cases,  however,  the  absence 
of  an^"  specific  character  about  the  sore,  its  immediate  occurrence  after 
connection,  the  general  known  tendency  of  the  patient  to  these  affec¬ 
tions,  and  the  fact  of  the  inguinal  glands  not  being  generally  indolently 
enlarged,  will  enable  the  Surgeon  to  diagnose  the  ulcer  to  be  simply  a 
local  affection,  and  not  the  prelude  to  general  syphilitic  eruptions. 
When  the  prepuce  is  in  a  state  of  infiammatoiy  phimosis,  it  is  always 
extremely  difficult  to  determine  by  mere  examination  whether  there  be 
chancres  under  it  or  not,  though  their  indurated  bases  may  sometimes 
be  felt  through  it.  In  the  case  of  the  phagedsenic  or  the  sloughy 
chancre,  there  can  be  little  difficulty  in  establishing  the  true  nature  of  the 
affection.  In  those  cases  in  which  a  comparison  of  the  characters  of  the 
sore  with  one  or  the  other  of  the  different  recognized  varieties  of  chancre 
failed  in  enabling  the  Surgeon  to  determine  the  true  nature  of  the  affec¬ 
tion,  it  was  thought  at  one  time,  when  the  local  contagious  ulcer  and 
the  phenomena  attending  the  progress  of  s^^philis  w^ere  confounded 
together,  that  the  infiuence  exercised  by  mercury  upon  the  sore  w'ould 
determine  whether  the  disease  were  syphilitic  or  not ;  the  true  chancres 
being  supposed  to  be  curable  in  no  other  way  than  b}'  the  internal 
administration  of  mercury;  but,  although  there  can  be  no  doubt  that  the 
influence  exercised  b}^  treatment  assists  the  Surgeon  considerably  in  the 
diagnosis  of  obscure  cases,  yet  it  cannot  be  relied  upon  as  a  test  of  the 
nature  of  the  disease,  man}^  venereal  affections  being  readil}^  curable 
b}"  very  simple  means  without  mercury.  It  must  be  further  recollected, 
that  little  practical  advantage  is  gained  by  experimenting  on  the  con¬ 
tagious  quality  of  the  discharge ;  because,  if  the  patient  have  been  ex¬ 
posed  to  syphilitic  contagion,  when  the  sore  comes  under  the  observa¬ 
tion  of  the  Surgeon  it  will  be  impossible  to  prevent  his  infection, 
which  will  have  taken  place  in  a  very  few  hours  after  the  application  of 
the  poison. 


LOCAL  TREATMENT  OF  CHANCRE. 


689 


Treatment  of  Chancre. — The  treatment  of  venereal  sores  has 
engaged  the  anxious  attention  of  the  most  eminent  Suro-eons :  and  so 
much  difference  of  opinion  and  practice  regarding  it  still  prevails,  that 
I  shall  not  endeavor  to  discuss  the  subject  generally,  but  rather  confine 
my  remarks  upon  it  to  that  form  of  treatment  which  has  met  with  the 
sanction  of  the  best  Surgeons  in  this  country,  and  which  a  tolerably 
extensive  experience  in  hospital  and  private  practice  has  led  me  to  con¬ 
sider  as  the  most  safe  and  effectual. 

The  treatment  of  chancre  is  of  a  local  and  of  a  constitutional  character. 
The  local  treatment  has  for  its  object  either  to  destroy  the  poisonous 
character  of  the  sore,  or  to  modify  it  so  as  to  bring  it  into  the  state  of  a 
healthy  ulcer ;  the  constitutional  treatment  is  not  onl}^  intended  to  facili¬ 
tate  this,  but  to  prevent,  if  possible,  infection  of  the  general  s^'stem  with 
the  poison  of  constitutional  syphilis,  should  this  have  been  communicated 
with  the  local  disease. 

Local  Treatment. — This  has  for  its  object  either  the  destruction  or  the 
modification  of  the  specific  character  of  the  sore.  The  complete  destruc¬ 
tion  of  the  local  virus  should  always,  if  possible,  be  effected  ;  and  if  this 
can  be  done  in  the  earl}"  stage  of  the  disease,  the  healing  of  the  sore  will 
be  much  expedited.  But,  even  though  considerable  time  have  passed 
before  a  Surgeon  sees  the  sore,  it  is  well  to  destroy  the  ulcerating  and 
poisonous  surface,  that  its  further  extension  may  be  prevented.  This 
should  be  effected  by  the  application  of  caustics  in  a  sufficiently  concen¬ 
trated  form  to  destroy  radically  and  at  once  the  specific  character  of  the 
sore,  so  as  not  only  to  save  the  pain,  but  to  prevent  the  irritation 
attendant  upon  frequent  applications.  The  nitrate  of  silver,  which  is 
commonly  used  for  this  purpose,  is  too  weak  to  secure  the  effect  it  is 
intended  to  accomplish,  being  apt  to  irritate  and  infiame,  and  not  to 
destroy  the  chancrous  surface,  thus  necessitating  repeated  and  painful 
applications.  I  consequently  prefer  to  this  the  strong  nitric  acid,,  one 
application  of  which  will  very  commonly  suffice  to  annihilate  the  specific 
character  of  the  sore :  though  more  energetic  in  action,  it  does  not  give 
rise  to  more  pain  than  the  nitrate  of  silver.  It  should  be  applied  b}" 
means  of  a  piece  of  wood,  a  glass  rod,  or  a  small  dossil  of  lint  wrapped 
round  the  end  of  a  silver  probe  ;  with  this  the  sore  may  be  freely  mopped, 
and  then,  a  stream  of  cold  water  having  been  poured  over  it  to  wash  away 
any  superfluous  acid,  a  light  poultice  or  a  piece  of  water-dressing  should 
be  laid  on  ;  after  the  small  slough  produced  b}"  the  caustic  has  separated, 
a  healthy  granulating  surface  will  be  left.  The  caustic  may  be  applied 
at  au}^  time  during  the  continuance  of  the  specific  condition  of  the  sore ; 
but  when  once  this  has  been  destroyed,  it  should  not  be  reapplied.  The 
potassa  fusa  and  the  potassa  cum  calce,  though  occasional!}^  used,  are 
far  less  manageable  and  not  more  efficacious  applications  than  the  nitric 
acid. 

These  are  the  means  that  are  generally  most  useful  in  Simple  Chancres. 
In  some  cases,  however,  inflammation  of  the  sore,  or  peculiarities  in  its 
situation,  demand  modifications  of  the  treatment. 

If  there  be  much  inflammation  about  the  sore  and  prepuce,  this  must 
first  be  subdued  by  the  application  of  cold  poultices,  or  of  lead  and  spirit 
lotion.  When  this  is  removed,  if  the  sore  have  not  lost  its  specific  cha¬ 
racter,  the  caustic  should  be  applied  in  the  usual  way. 

Should  there  be  phimosis  with  discharge  of  chancrous  pus  from  under 
the  tightened  prepuce,  it  will  be  better  to  slit  this  up,  so  as  to  expose 
and  freely  cauterize  the  subjacent  chancres.  If  the  cut  edges  of  the 
prepuce  become  inoculated,  they  must  also  be  cauterized  freely  and  early. 

VOL.  I _ 44 


690 


VEXEREAL  DISEASES. 


If  the  chancres  be  situated  round  the  orifice  of  an  elongated  and  tisht 
prepuce,  circumcision  is  the  best  means  of  removing  the  disease  and  the 
inconvenience  at  the  same  time.  The  cut  surface,  however,  will  always 
become  infected,  and  require  to  be  freely  cauterized  with  nitric  acid. 

After  the  slough  produced  by  the  caustic  has  separated,  the  surface 
may  begin  to  granulate  healthily  at  once,  requiring  but  simple  dressings  ; 
but  in  the  majorit}’  of  cases  it  will  continue  in  a  somewhat  unhealthy 
condition,  demanding  special  topical  applications  to  cause  it  to  cicatrize 
soundly.  If  it  be  weak  and  fungating,  an  astringent  lotion,  such  as  the 
following,  will  be  found  more  useful:  R  Tannin,  9j  ;  Tinct.  lavanduse 
comp.  5ij  ;  Yini  rubri,  5iv.  Ft.  lotio.  Or  a  solution  of  sulphate  of  cop- 
i:)er  may  be  applied,  and  the  sore  touched  from  time  to  time  with  nitrate 
of  silver.  If  there  be  induration  at  its  base,  the  black  or  yellow  wash 
will  perhaps  be  found  the  best  application  that  can  be  used. 

When  the  chancre  is  indurated  bj^  s^’philis,  no  attempt  should  be  made 
to  burn  away  the  indurated  base  with  caustics,  as  it  will  prove  unsuc¬ 
cessful,  the  cause  of  the  induration  being  always  beyond  the  influence  of 
the  caustic.  In  these  cases,  the  best  local  application  is  generally  the 
black  wash. 

In  the  Phagedsenic  Chancre  a  different  management  is  required.  If 
there  be  much  irritabilit}^  about  the  sore,  the  nitric  acid  cannot  be  borne  ; 
and  here  the  best  application  is  an  opiate  lotion,  conjoined  perhaps  with 
small  quantities  of  the  chloride  of  soda.  If  the  part  require  more  stimu¬ 
lation,  a  few  drops  of  the  dilute  nitric  acid  may  advantageously  be  added 
instead  of  the  chloride.  In  these  cases,  however,  the  application  of  the 
strong  nitric  acid  ma}^  often  be  required  at  a  later  period,  on  the  removal 
of  the  local  irritation  by  the  topical  emplo3’ment  of  sedatives.  In  many 
cases,  the  local  inflammatory  action  is  best  removed  at  first  b^"  the  appli¬ 
cation  of  the  concentrated  nitric  acid,  this  being  followed  bj-  opiate 
lotions  or  emollient  poultices,  and  the  caustic  being  reapplied  whenever 
there  is  a  tendency  to  extension  of  the  disease. 

In  Sloughing  Chancre^  when  the  prepuce  is  greatly"  tumefied,  in  a  state 
of  inflammatory  phimosis,  and  of  a  deep  red  or  purplish  color,  with 
threatening  of  extensive  gangrenous  action,  a  director  should  be  passed 
between  it  and  the  glans  penis,  and  the  swollen  prepuce  slit  up.  In  this 
way  tension  is  removed,  and  the  extension  of  the  sloughing  action 
arrested.  An}^  chancre  that  is  exposed  must  then  be  freely  touched  with 
nitric  acid.  Should  the  parts  alread\^  have  fallen  into  a  state  of  gan¬ 
grene,  emollient  and  antiseptic  applications  will  generall}^  be  found  to 
agree  best :  yeast,  carrot,  opiate,  charcoal,  or  chlorinated  poultices  should 
be  emplo3'ed,  the  sloughs  removed,  and  an3^  parts,  as  portions  of  the 
prepuce,  that  are  partially  destro3^ed  by  the  gangrenous  action,  slit  up, 
so  as  to  remove  tension  and  lessen  inflammation.  In  cases  of  inflamma- 
toiy  sloughing  of  the  penis,  the  hemorrhage,  that  occasionall3^  results 
from  some  of  the  bloodvessels  of  the  organ  being  opened  by  this  action, 
ma3^,  if  moderate,  be  looked  upon  as  highl3^  beneficial,  inasmuch  as  it  is 
often  followed  b3^  an  arrest  of  the  morbid  process.  If,  however,  it  occur 
to  an  alarming  extent,  the  patient  should  be  put  under  chloroform  and 
the  actual  cautery  freely  applied.  This  not  only  stops  the  bleeding,  but 
arrests  the  progress  of  the  sloughing  action.  When  once  the  chancre  is 
liealthil3^  granulating,  it  must  be  dressed  in  the  same  wa3^  as  an3’  common 
ulcer. 

In  using  lotions  to  any  form  of  chancre,  care  should  always  be  taken 
to  keep  a  piece  of  lint  soaked  in  the  fluid  constantl3^  applied  between  the 
prepuce  and  the  glans,  and,  in  women,  between  the  opposite  labia;  for. 


CONSTITUTIONAL  TREATMENT  OF  CHANCRE.  691 


unless  this  be  clone,  the  contact  of  the  diseased  and  inflamed  mucous 
surfaces  with  one  another  will  tend  to  keep  up  irritation  and  morbid 
action. 

Constitutional  Treatment. — The  Simple^  Soft,  or  Excoriated  Chancre 
will  readily  heal  under  non-mercurial  treatment ;  but,  contrary  to  the 
opinion  of  many  Surgeons  of  the  present  day,  I  consider  it  much  safer 
to  put  the  patient  upon  a  mild  course  of  the  iodide  of  mercury. 

The  constitutional  treatment  of  Phagedaenic  Chancre  must  be  directed 
by  general  medical  principles ;  rest  in  bed,  a  mild  diet,  the  administra¬ 
tion  of  salines  and  opiates,  in  those  cases  in  which  there  is  inflammation 
and  irritation  conjoined ;  whilst  in  those  in  which  there  is  a  debilitated 
or  cachectic  condition,  tonics,  such  as  bark  or  iron,  with  good  food  and 
stimulants,  may  be  required,  together  with  opiates  to  allay  pain  and  to 
procure  rest.  The  preparations  of  iron,  especially  the  ammonio-citrate 
and  potassio-tartrate,  either  alone  or  in  combination  with  sarsaparilla, 
are  especiall}'’  useful  in  these  cases.  In  the  phagedmnic  chancre  mercury 
is  seldom  admissible,  and  does  much  harm  if  employed  to  check  any 
syphilitic  taint  that  may  be  present  with  the  sore.  .Indeed,  it  is  the 
indiscriminate  use  of  mercuiy  in  these  cases  that  has,  I  believe,  brought 
so  much  discredit  upon  this  remedj^  in  venereal  diseases.  But,  although 
mercury  is  not  generall}"  admissible  in  phagedmnic  chancre,  yet,  in  that 
form  that  is  characterized  by  a  white  slough,  it  has  been  found  useful  by 
Wallace,  and  the  utility  of  this  practice  I  can  confirm,  having  found  it 
of  service  in  some  of  the  more  rebellious  varieties  of  this  disease ;  the 
mineral  must,  however,  be  very  cautiously  administered,  and  in  but  small 
doses. 

In  the  Gangrenous  or  Sloughing  Chancre.,  the  constitutional  powers 
of  the  patient  will  be  found  to  be  broken,  and  his  general  health  de¬ 
pressed,  so  that  depletory  measures  are  seldom  if  ever  required.  The 
prepuce  should  be  slit  up,  and  free  incisions  should  be  made  through 
the  sloughing  textures,  so  as  to  take  down  all  tension  ;  and  as  the  fever 
subsides,  or  from  the  first  if  there  be  much  asthenia,  ammonia  and  bark, 
good  nourishment,  and  abundant  stimulants,  will  be  required ;  eventu¬ 
ally  the  patient’s  strength  may  be  supported  by  iron  and  quinine,  and 
the  irritabilit}-  of  the  system  alla3^edb3’'  the  free  administration  of  opium  ; 
the  strong  nitric  acid  should  then  be  mopped  freel3^  over  the  parts,  and 
afterwards  charcoal  or  3’east  poultices  applied  until  the  sloughs  have 
separated.  After  the  separation  of  the  sloughs,  the  sore  will  usualh^ 
present  a  clean  appearance,  the  granulations  cicatrizing  rapidly.  It 
often  happens  that,  when  a  portion  01113^  of  the  prepuce  has  been  de- 
stro3"ed,  the  iqDper  part  being  perforated,  and  the  preputial  orifice,  with 
the  under  part  hanging  down  under  the  glans,  the  part  thus  projecting 
ma3^  be  snipped  oflT  with  advantage,  and  the  organ  thus  moulded  into  a 
better  shape. 

After  a  chancre  has  been  healed  in  one  or  other  of  these  ways,  we  must 
endeavor,  by  the  general  improvement  of  the  patient’s  health,  to  prevent 
or  alleviate  the  manifestation  of  syphilis,  should  that  malad3^  have  been 
contracted  at  the  time  of  contagion.  This  is  usuall3’’  best  done  by  put¬ 
ting  him  on  a  course  of  sarsaparilla  with  the  mineral  acids,  and  b3' 
scrupulous  attention  for  some  months  to  his  habits  of  life.  The  S3q)hi- 
litic  poison  ma3^  linger  for  a  greath  length  of  time  in  the  S3"stem,  not 
declaring  itself  b3^  an3"  overt  manifestation  so  long  as  the  health  con¬ 
tinues  good  ;  but,  if  the  patient  fall  into  a  debilitated  state,  even  though 
some  years  have  elapsed,  showing  itself  by  some  of  its  local  effects. 


692 


VENEREAL  DISEASES. 


CONSECUTIVE  SYMPTOMS  OF  THE  LOCAL  CONTAGIOUS  ULCER. 

Chancres  are  not  unfrequently  followed  by  a  series  of  affections 
which  may  be  termed  consecutive^  depending  as  they  do  upon  the  primary 
disease,  but  being  local  in  their  character,  and  presenting  no  evidence 
of  constitutional  infection.  These  consecutive  symptoms  are  three  in 
number  :  viz..  Contraction  of  the  Chancrous  Cicatrix,  Bubo,  and  Warts. 

Contracted  Cicatrices. — Most  excoriated  chancres  are  healed  with¬ 
out  any  cicatrix  or  other  trace  of  them  being  left ;  but,  in  the  phagedsenic 
and  the  sloughing  chancres,  there  is  always  loss  of  substance,  often  to  a 
considerable  extent,  and  consequently  a  depressed  scar.  But  in  addition 
to  these  thickenings,  one  of  another  kind  may  take  place.  The  situa¬ 
tions  of  all  venereal  ulcers  should  be  watched  for  some  time,  however 
readily  the  sore  may  have  healed ;  lest,  the  syphilitic  virus  having  been 
introduced  with  the  local  irritant,  induration  should  commence  at  the 
point  of  contagion,  when  the  time  of  incubation  or  inactivity  of  the  virus 
after  its  introduction  has  elapsed.  Thus,  a  month  or  six  weeks  should 
pass  away  after  the  suspicious  connection,  before  the  Surgeon  pro¬ 
nounces  the  patient  free  of  general  syphilis. 

Bubo. — By  bubo  is  meant  an  inflammatory  enlargement  of  the  lym¬ 
phatic  glands  which  receive  the  lymphatic  vessels  supplied  to  the  inocu¬ 
lated  surface.  A  bubo,  though  generally  produced  in  the  groin  by 
absorption  of  irritating  matter  from  chancres  on  the  penis,  may  occur 
elsewhere  ;  as,  for  instance,  in  the  axilla,  in  cases  of  chancre  on  the  fin¬ 
ger  ;  in  the  submaxillary  region,  if  the  disease  occur  on  the  lij).  The 
enlargements  of  the  inguinal  or  other  lymphatic  glands  that  occur  in 
cases  of  venereal  chancre,  are  caused  by  several  kinds  of  irritation.  The 
glands  may  be  irritated  by  concomitant  inflammatory  action  about  the 
penis,  as  when  balanitis  or  phimosis  is  present ;  or  they  may  be  en¬ 
larged  from  the  simple  excitement  of  the  parts,  especially  in  strumous 
and  debilitated  subjects.  In  these  cases  the  bubo  is  termed  Sympathetic^ 
and  the  affection  must  be  considered  as  a  simple  irritation  and  inflam¬ 
mation  of  the  inguinal  glands,  which  may  speedily  subside  under  proper 
antiphlogistic  treatment  of  a  mild  kind,  although  in  many  cases  suppu¬ 
ration  eventually  takes  place,  constituting,  in  fact,  a  simple  glandular 
abscess,  presenting  nothing  in  any  way  specific.  Indeed,  it  scarcely 
ever  happens  that  a  chancre  has  existed  for  some  days  without  the  lym¬ 
phatic  glands  in  the  groin  becoming  enlarged  and  somewhat  indurated, 
especially  those  that  lie  parallel  to  Poupart’s  ligament,  their  enlargement 
being  attended  with  a  degree  of  stiffness  and  dragging  pain.  The 
liability  to  this  irritation  and  inflammation  of  the  glands  in  the  groin  is 
greatly  increased  by  the  patient  walking  about  or  otherwise  exerting 
himself.  But  I  do  not  think  that  causes  such  as  these  influence  the 
occurrence  of  the  other  and  more  serious  affection  of  the  lymphatic 
glands;  namely,  the  virulent  bubo,  which  appears  to  originate  from 
direct  absorption  of  the  chancrous  pus,  without  the  interference  of  any 
external  agency.  When  once  the  glands  in  the  groin  have  become  viru¬ 
lently  irritated,  it  is  extremely  difficult,  if  not  impossible,  to  prevent 
suppuration  from  taking  place.  Most  usually  only  one  or  two  glands 
suppurate,  although  several  may  be  enlarged  ;  and  very  commonly  the 
disease  is  confined  to  one  groin  only,  though  both  may  be  affected,  more 
particularly  if  the  chancre  be  situated  upon  the  frsenum.  The  suppura¬ 
tion  ma}^  be  limited  to  the  gland  immediately  affected,  or  it  may  extend 
into  the  surrounding  areolar  tissue,  or  even  be  chiefly  confined  to  this. 

The  true  specific  virulent  bubo  is  essentially  produced  by  the  absorp- 


TREATMENT  OF  BUBO. 


693 


tion  and  deposit  of  the  venereal  virus  in  the  substance  of  the  gland,  the 
tissue  of  which  becomes  poisoned  ;  so  that  we  may  consider  with  Ricord 
that  a  virulent  bubo  is,  properly  speaking,  a  chancre  of  an  absorbent 
gland,  differing  only  in  seat  from  that  which  is  situated  upon  the  sur¬ 
face  of  the  body.  Ricord  has  observed,  and  I  have  often  had  an  oppor- 
tunitj’^  of  testing  the  correctness  of  this  observation,  that  the  pus  of  a 
virulent  bubo  is  as  readily  inoculable  as  that  of  an  ordinary  chancre. 
This  kind  of  bubo,  then,  may  be  considered  as  a  specific  abscess  of  the 
absorbent  glands  and  surrounding  areolar  tissue.  It  runs  the  ordinary 
course  of  an  acute  abscess,  often  undermines  the  skin  to  a  considerable 
extent,  with  much  red  or  purple  discoloration,  and,  when  it  has  burst  or 
been  opened,  presents  a  ragged  sloughy-looking  cavity,  having  an  un¬ 
healthy  appearance :  it  most  usually  occurs  about  the  second  or  third 
week  after  the  first  appearance  of  the  chancre,  but  may  happen  at  an 
earlier  or  at  a  later  period,  even  after  the  chancre  has  itself  healed. 

Primary  Buho. — The  French  Surgeons  have  described  a  form  of  bubo 
that  tliej’’  call  bubon  Pemblee  ov  primary  bubo  ;  this  is  said  to  occur  from 
the  direct  absorption  of  the  chancrous  matter,  without  the  previous  for¬ 
mation  of  a  chancre.  Scarcely  any  satisfactory  proof,  however,  has 
been  given  of  the  existence  of  such  a  bubo.  It  frequently  happens  that 
small  excoriated  chancres  heal  in  a  few  days,  before  which  time,  however, 
the  inguinal  glands  have  become  irritated  and  enlarged ;  and  as  the 
enlargement  of  the  glands  goes  on  after  the  healing  of  the  chancre,  a 
bubo  may  be  formed  when  all  trace  of  its  primary  source  has  entirely 
disappeared. 

This  primary  bubo  has  fallen  under  my  observation  in  one  case  only. 
Until  that  occurred,  I  doubted  its  existence;  and  I  am  not  yet  fully 
convinced  that  this  suggested  mode  of  origin  is  the  true  one.  In  the 
case  referred  to,  a  young  man  applied  to  me  with  a  rather  large  abscess 
in  the  groin,  for  which  I  sent  him  into  the  Hospital.  On  being  ques¬ 
tioned,  he  denied  ever  having  had  any  venereal  disease,  though  he  ad¬ 
mitted  having  had  intercourse  with  a  woman  of  the  town.  On  examining 
the  penis,  no  chancre,  abrasion,  or  citatrix  could  be  discerned.  The 
abscess  was  opened,  and  two  ounces  of  rather  bloody  and  very  thick 
pus  were  let  out ;  no  enlarged  glands  could  be  seen.  For  the  sake  of 
experiment  the  pus  was  inoculated  into  the  left  thigh,  and  two  distinct 
and  well-marked  pustules  were  produced.  That  such  an  effect  can  be 
obtained  by  matter  of  very  irritable  character  wdthout  any  venereal 
origin,  is  shown  by  the  experiments  of  several  Surgeons  who  have  suc¬ 
ceeded  in  inoculating  matter  from  itch  and  ecthymatous  pustules  ;  hence 
it  must  not  be  concluded  in  this  case  that  the  bubo  was  consequent  on 
the  direct  absorption  of  venereal  matter  along  the  lymphatics. 

Creeping  Bubo. — In  some  cases  the  bubo,  as  has  been  well  shown  by 
Solly,  assumes  a  tendency  to  creep  or  spread  over  the  neighboring  in¬ 
tegument,  extending  in  this  way  to  a  considerable  distance  down  the 
thigh,  upon  the  abdomen,  or  over  the  ilium.  This  creeping  buho  is  cha¬ 
racterized  by  the  peculiar  semicircular  or  horseshoe  shape  that  the  sore 
assumes,  and  by  its  tendency  to  cicatrize  by  one  margin,  whilst  it  slowly 
extends  by  the  other ;  the  cicatrix  always  being  thin,  blue,  and  weak, 
closely  resembling  that  of  a  burn. 

After  a  bubo  has  disappeared,  a  good  deal  of  induration  may  be  left 
in  the  glands  of  the  groin,  perhaps  with  matting  of  the  surrounding 
areolar  tissue ;  and  this  induration  may  continue  for  years,  or  even  for 
the  remainder  of  life. 

The  Treatment  of  bubo  consists,  in  the  first  instance,  in  endeavoring 


694 


VENEREAL  DISEASES. 


to  prevent  the  occurrence  of  suppuration ;  and  should  this  take  place, 
in  letting  out  the  matter  and  closing  the  wound  which  results. 

The  Preventive  Treatment  of  bubo  is  of  considerable  moment ;  for, 
if  suppuration  take  place,  a  tedious  result  will  often  be  entailed  on  the 
patient.  It  consists  essentially  in  perfect  rest  of  the  part,  and  the 
application  of  leeches  and  of  cold  lead  poultices.  In  reference  to  the 
application  of  leeches,  there  is  a  practical  point  of  considerable  impor¬ 
tance  that  requires  attention — viz.,  that  the  leech-bites  may  become 
infected  by  the  chancrous  pus,  and  thus  converted  into  a  number  of  new 
chancres.  This  accident  is  best  guarded  against  by  covering  the  bites 
with  collodion  and  plaster. 

If  there  be  not  much  inflammatory  action  about  the  bubo,  but  this  be 
indolent  and  chronic,  the  application  of  blisters,  of  discutient  plasters, 
or  of  the  tincture  of  iodine,  is  occasionally  useful.  A  plan  of  discutient 
treatment  recommended  by  a  French  army-surgeon,  Malplaquet,  I  have 
found  very  serviceable  in  several  cases.  It  consists  in  applying  a  blister 
about  as  large  as  a  half-crown  over  the  surface  of  the  inflamed  gland, 
and  dressing  the  raw  surface  produced  by  it  with  a  piece  of  lint  soaked 
in  a  saturated  solution  of  the  bichloride  of  mercury  for  a  couple  of  hours, 
w’hen  a  white  eschar  will  have  formed ;  a  cold  poultice  should  then  be 
applied,  and  continued  until  all  excited  action  has  gone  down. 

If,  notwithstanding  our  endeavors  to  prevent  suppuration,  matter  form 
within  or  around  the  gland,  as  evinced  by  the  swelling  becoming  soft, 
boggy,  and  inflamed,  it  should  be  freely  opened  by  either  a  horizontal 
or  a  vertical  incision,  wdiichever  will  give  the  readiest  outlet  to  the  pus. 
If  the  integuments  be  much  thinned,  undermined,  and  of  a  bluish  color, 
I  prefer  making  the  opening  with  potassa  fusa,  as  it  destroys  those  un¬ 
healthy  tissues  which  w’ould  otherwise  interfere  with  the  cicatrization  of 
the  wound.  The  cavity  that  is  now  exposed  presents  a  chancrous  ap¬ 
pearance,  being  irregular  and  sloughy,  with  elevated  and  angry  red  edges. 
This  should  be  dressed  with  the  aromatic  wine  and  tannin  lotion  (p.  690). 
If  the  character  of  the  sore  do  not  improve,  the  potassa  fusa  should  be 
freely  applied  to  its  surface  and  edges,  and  after  the  sloughs  have  sepa- 
pated,  the  granulations  may  be  dusted  with  red  precipitate  powder;  the 
cicatrization  will  in  many  cases  be  much  facilitated  by  the  application 
of  a  compress  with  a  spica  bandage,  and  by  keeping  the  patient  at  rest. 
Not  unfrequently  the  healing  of  the  sore  is  interfered  with  by  the  over¬ 
hanging  of  the  undermined  edges ;  these  may  occasional!}^  be  made  to 
retract  by  being  freely  rubbed  with  the  nitrate  of  silver.  If  this  do  not 
succeed,  it  may  be  necessary  to  pare  them  off  with  a  knife  or  scissors, 
or  to  destroy  them  with  potassa  fusa ;  the  sore  should  then  be  dressed 
from  the  bottom,  and  treated  on  general  principles.  Sometimes  slough¬ 
ing  action  is  set  up  in  the  open  bubo,  and  then  extensive  destruction  of 
tissue  may  ensue,  and  even  fatal  hemorrhage  from  the  femoral  artery  has 
been  known  to  occur.  If  there  be  signs  of  syphilis  concomitant  with 
this  local  bubo,  such  as  several  indurated  glands,  or  rash  upon  the  skin, 
it  is  as  necessary  to  employ  the  continuous  administration  of  mercury 
to  cure  the  latter  disease,  as  if  the  local  affection  were  not  present. 

Venereal  Warts. — Various  forms  of  warts  occur  independently  of 
an}^  constitutional  affection,  from  simple  continued  irritation  of  the  muco¬ 
cutaneous  surfaces.  They  commonly  occur  on  the  prepuce  or  glans,  and 
are  especially  apt  to  be  situated  in  the  angle  between  these  parts;  they 
are  of  a  bright  red  color,  very  vascular,  and,  if  left  without  interference, 
may  increase  immensel}"  in  size  and  number,  distending  the  prepuce,  and 
giving  a  clubbed  appearance  to  the  penis ;  there  is  always  phimosis 


CONSTITUTIONAL  VENEREAL  DISEASE. 


695 


attending  them,  and  the  tension  of  the  prepuce  may  be  sucli,  that  ulce¬ 
ration  occasionally  takes  place  in  it,  giving  rise  to  a  protrusion  of  these 
growths  through  an  aperture  in  its  side.  These  warts  are  occasionally 
met  with  in  the  vagina,  forming  large,  irregular,  cauliflower-looking 
masses.  The  Treatment  consists  in  snipping  and  paring  them  off  with 
scissors,  and  afterwards  touching  the  parts  from  which  they  spring  with 
nitrate  of  silver,  to  prevent  their  recurrence.  In  order  to  do  this  effec¬ 
tually,  it  is  necessarj''  to  lay  open  the  prepuce  in  all  those  cases  in  which 
the  glans  cannot  be  freely  exposed  by  drawing  this  back. 

II.— SYPHILIS,  OR  CONSTITUTIONAL  VENEREAL  DISEASE. 

Syphilis  is  a  specific  disease,  transmissible  (1)  b3^  the  contact  of  its 
own  specific  pus  with  a  tender,  or,  at  least,  an  abraded  surface;  (2)  b}’- 
inoculation  into  the  s^’-stem  through  the  medium  of  the  secretions ;  or 
(3)  by  hereditarj’-  taint  under  certain  special  conditions.  It  manifests 
itself  not  so  much  hy  the  occurrence  of  any  one  special  affection,  as  by 
producing  a  tendency  to  inflammation  in  various  tissues  and  organs,  and 
b}’’  impressing  a  peculiar  form  and  course  on  the  inflammatory  affections 
which  it  induces. 

The  early  and  more  common  consequences  of  this  affection  have  long 
been  called  primary  and  secondary  s^q^hilis.  These  terms  are  ill  suited 
to  our  present  knowledge  of  syphilis,  for  it  is  now  established  that  the 
induration  at  the  point  of  contagion  and  the  enlargement  of  the  neighbor¬ 
ing  Ij^mphatic  glands  are  as  much  a  part  of  the  disease  as  are  the  erup¬ 
tions  of  the  skin  and  mucous  membranes;  which,  in  the  great  majority 
of  cases,  shortly  follow  the  appearance  of  the  former.  But,  as  they  have 
the  sanction  of  custom,  they  may  be  employed  to  indicate  the  different 
phenomena  of  the  disease.  Thus,  Primary  Syphilis  is  used  to  denote 
the  induration  and  ulceration  that  take  place  at  the  point  of  contagion, 
and  the  indolent  enlargement  of  the  nearest  group  of  the  Ij^mphatic 
glands.  Secondary  Syphilis  denotes  the  various  eruptions  of  the  skin 
and  mucous  membranes,  and  the  inflammation  of  the  e3’'e  and  the  peri¬ 
osteum,  which  take  place  in  the  first  two  years  after  contagion,  but  ma3' 
return  b3"  relapses  of  the  disease  after  much  longer  periods.  Lastly,  the 
term  Tertiary  Syphilis  includes  peculiar  consequences  of  S3q)hilis  that 
appear  in  a  small  proportion  onl3’’  of  those  infected,  and  which  affect  the 
bod3^,  especiall3'  the  viscera,  with  processes  of  a  slow  inflammatoiy  cha¬ 
racter,  and  are  seldom  set  in  action  until  the  ordinaiy  course  of  the  dis¬ 
ease  has  terminated. 

S3q)hilis  ma3",  then,  be  regarded  as  presenting  two  orders  of  symptoms, 
the  local  and  the  constitutional.  The  Local  or  Primary  symptoms 
occur  only  on  the  part  to  whicli  the  virus  is  immediatel3^  applied,  and  are 
the  consequences  of  the  introduction  of  the  poison  at  the  point  of  inocu¬ 
lation.  The  Constitutional  or  Secondary  symptoms  are  the  results  of  the 
absorption  of  the  poison  into  the  economy,  whereby  most  of  the  tissues 
and  man3’'  of  the  organs  of  the  body  are  affected ;  they  are  capable  of 
hereditaiy  propagation,  and,  in  certain  circumstances,  of  transmission 
through  the  secretions. 

It  would  be  altogether  foreign  to  the  scope  of  this  work  were  I  to  enter 
into  the  very  curious  and  interesting  question  as  to  the  origin  o  f  syphilis^ 
a  subject  that  admits  of  much  dispute,  and  which  has  been  keenl3’’  argued. 
After  an  attentiv'e  examination  of  it,  I  think  there  can  be  little  doubt 
that  S3’’philis  was  either  introduced  into  Europe,  or  originated  there  de 
novoj  towards  the  end  of  the  fifteenth  centuiy.  There  is  no  mention 


696 


VENEREAL  DISEASES. 


made  by  the  medical  writers,  historians,  or  poets  of  antiquity  of  any 
contagious  disease  arising  from  sexual  intercourse  affecting  the  genital 
organs,  and  followed  by  constitutional  symptoms.  The  disease,  when  it 
first  attracted  public  attention  at  the  close  of  the  fifteenth  century,  was 
looked  upon  as  a  new  and  previously  unknown  affection.  It  was  sup¬ 
posed  to  be  infectious  as  well  as  contagious,  and  its  treatment  was  not 
understood.  This  would  scarcely  have  been  the  case  had  it  been  pre¬ 
viously  known  by  personal  observation,  or  even  by  tradition,  to  those 
then  living.  If  it  had  previously  existed  in  the  old  world  in  a  mild  or 
modified  form,  different  from  what  we  now  observe,  it  is  certain  that 
about  this  time  it  suddenly  assumed  great  intensit3q  all  its  symptoms 
being  aggravated  in  a  remarkable  and  fearful  manner,  presenting  cha¬ 
racters  which  had  not  been  previously''  alluded  to,  but  which  have  often 
been  reproduced  in  modern  times  ;  as,  for  instance,  in  those  severe  forms 
that  were  observed  in  the  British  armies  during  the  Peninsular  War,  and, 
according  to  Larrey,  among  the  French  troops  during  Napoleon’s  Ger¬ 
man  campaigns. 

Transmissibility  of  Syphilis. — That  syphilis  can  be  communi¬ 
cated  through  the  contact  of  its  specific  pus  with  an  abraded  or  tender 
surface,  is  fully''  established ;  but  the  question  as  to  the  contagiousness 
of  secondary  syphilitic  discharges,  or  of  the  secretions  of  individuals 
laboring  under  constitutional  syphilis,  is  one  that  is  still  unsettled;  and, 
before  it  can  be  settled,  very  extended  and  accurate  observation  is 
required  for  the  elimination  of  those  sources  of  error,  which  are  insepa¬ 
rable  from  an  inquiry  in  which  the  morality''  of  patients  often  constitutes 
an  important  element.  The  following  appear  to  me  to  be  the  chief  points 
that  may  be  looked  upon  as  decided  with  tolerable  certainty,  though 
many  of  them  are  still  subjects  of  controversy. 

Constitutional  syphilis  is  contagious  ;  that  is  to  say,  it  is  communicable 
from  one  individual  to  another  through  the  medium  of  the  discharge  of  one 
of  the  sores  that  may  form  during  its  continuance.  The  fluids  which 
by^  direct  experiment  are  proved  to  contain  the  virus  in  a  communicable 
form,  are  the  secretions  of  all  the  early  syphilitic  eruptions;  of  these, 
the  most  common  are  the  thin  discharge  of  mucous  tubercles,  or  of  the 
initial  ulcer.  The  blood  itself,  in  more  than  one  instance,  has  been  inocu¬ 
lated  with  success.  Professor  Pellizzari,  of  Florence,  inoculated  a  y^oung 
Surgeon,  Dr.  Bargioni,  on  the  6th  of  Februaiy,  1860,  with  blood  taken 
from  the  vein  of  a  woman  suffering  from  syqffiilitic  eruptions.  The  site  of 
the  inoculation,  which  was  carefully  protected  by  a  watch-glass  cover, 
remained  quiet  for  twenty-five  day^s ;  then  a  papula  developed,  which  in 
forty^-four  day^s  became  an  ulcer  with  hard  base.  On  the  sixty-fifth  day 
after  inoculation,  a  roseola  broke  out  on  the  trunk.  Some  uncertainty 
still  exists  as  to  whether  the  natural  secretions  of  syqDhilitic  persons  are 
contagious  of  themselves,  or  become  so  by  admixture  with  the  blood  or 
the  discharge  of  syphilitic  affections.  The  saliva,  the  milk,  and  the 
semen  have  been  variously  accused  of  this  power.  Syphilis  is  hereditarily 
transmissible  from  parent  to  offspring;  it  is  said  to  be  communicable  to 
the  female  by^  impregnation  by  a  diseased  male,  and  even  through  the 
medium  of  the  semen  without  impregnation.  It  is  also  believed  by  some 
to  be  communicable  to  the  mother  from  a  diseased  foetus  in  utero,  the 
parent  being  thus  poisoned  through  her  own  offspring.  There  are  cer¬ 
tain  rare  cases  in  which  it  has  been  communicated  from  nurses  to  children, 
and  vice  versd^  in  the  act  of  suckling,  through  the  medium  of  sores  or 
mucous  tubercles  on  the  nipple  or  mouth,  and  possibly^  through  the  secre¬ 
tions.  And  there  occasionally  occur  cases  in  which  the  male  is  infected 


TRAXSMISSIBILITY  OF  SYPHILIS. 


697 


by  the  diseased  secretions  of  a  syphilitic  female  during  sexual  inter¬ 
course,  without  there  being  any  local  sore  through  which  the  poison  can 
be  proved  to  be  conveyed  into  the  system. 

Ought  a  man  affected  by  constitutional  syphilis  to  many?  is  a  ques¬ 
tion  that  is  frequently  put  to  the  Surgeon,  and  one  to  which  it  is  b}’-  no 
means  easy  to  give  a  direct  and  immediate  answer.  That  a  man  labor¬ 
ing  under  constitutional  syphilis  is  liable  to  infect  a  healtly  woman, 
either  directly  or  through  the  medium  of  her  foetus,  or  to  become  the 
progenitor  of  syphilized  children,  there  can  be  no  doubt ;  but  that  he 
will  necessaril}^  do  so,  is  certainly  not  the  case.  In  answering  the  diffi¬ 
cult  question  that  is  thus  frequentlj"  raised,  the  Surgeon  must  be  very 
cautious;  he  must  bear  in  mind  that  the  health  and  happiness  of  a  woman 
and  the  future  of  a  family  are  often  dependent  on  his  reply ;  and  that, 
should  he  give  his  consent  to  the  union  and  evil  consequences  follow,  the 
whole  responsibility  will  be  thrown  upon  him.  I  think  that  it  may  be 
stated  generally,  that  no  man  ought  to  marry  for  at  least  twelve  months 
after  the  first  development  of  constitutional  S3q)hilis,  even  though  all 
local  signs  of  the  disease  have  disappeared,  and  that  he  ought  not  to  do 
so  whilst  any  local  manifestations  of  the  disease  are  developing  them¬ 
selves,  whatever  time  has  elapsed  since  the  commencement  of  the  attack. 
But,  although  I  believe  that  it  is  safer  to  follow  these  general  rules,  yet 
I  have  seen  so  man}’’  cases  in  which  marriage  has  been  contracted  by 
men  still  sufferino:  from  occasional  manifestations  of  the  sliohter  forms 
of  constitutional  syphilis,  and  yet  no  evil  consequences  have  been  entailed 
either  in  wife  or  children,  that,  although  it  may  be  safer,  yet  it  cannot 
be  absolutely  necessary  to  adhere  closely  to  the  advice  just  given.  I 
know  instances  in  which  men  who  had  contracted  S3’philis  before  mar¬ 
riage,  and  had  been  imperfectl}"  cured — having  for  many  3^ears  (ten, 
fifteen,  or  even  twenty)  occasional  outbreaks  of  cutaneous  S3q3hilides, 
sarcocele,  gummata,  and  other  varieties  of  the  advanced  forms  of  the 
disease — have  been  the  parents  of  perfectl}'  health}’  children,  and  have 
never  infected  their  wives. 

It  is  tolerably  well  established  that  S3'philis  is  occasional!}^  communi¬ 
cated  with  other  affections.  The  matter  of  local  chancre  may  thus  be 
contaminated  with  the  syphilitic  virus,  if  the  two  affections  be  present 
in  the  same  person.  Syphilis  has  also  been  spread  widely  among  young 
children  by  vaccinating  them  with  lymph  from  a  syphilitic  child.  One 
of  the  most  unquestionable  of  these  accidents  is  th»t  which  occurred  in 
the  Subapennine  valley  of  Rivalta  in  Piedmont,  in  1861.  Dr.  Pacchi- 
otti,  of  Turin,  who  was  employed  by  the  Italian  government  to  report 
on  the  attack,  has  published  an  account  of  it.  The  facts  are  shortly 
these.  In  May,  1861,  an  apparently  healthy  child,  named  Chiabrera, 
was  vaccinated  at  Rivalta  with  lymph  sent  from  Acqui  for  the  purpose. 
Ten  days  after  this  vaccinnation — on  June  Tth — forty-six  healthy  chil¬ 
dren  were  vaccinated  at  one  sittinsr  from  this  child.  Asrain  on  the  12th 
June,  seventeen  other  healthy  children  were  vaccinated  from  one  of  the 
forty-six.  Thirty-nine  of  the  first  series  of  forty-six,  and  seven  of  the 
second  series  of  seventeen,  received  syphilis  with  the  vaccine  disease, 
making  a  total  of  forty-six  out  of  sixty-three  children  in  a  mountain 
village  simultaneously  inoculated  with  syphilis.  Some  months  elapsed 
before  the  vaccination  was  suspected  to  have  been  the  source  of  the 
children’s  bad  health.  By  the  Tth  October,  when  attention  was  drawn 
to  this  spreading  disease,  six  of  the  forty-six  syphilized  children  had 
died  without  receiving  any  treatment,  fourteen  were  recovering,  and 
three  were  in  a  precarious  condition.  Twenty-three  were  dispersed 


698 


VENEREAL  DISEASES. 


through  the  country,  and  their  condition  was  unknown  until  further 
researches  traced  them  out.  In  addition  to  the  children,  twenty'’  women 
suckling  them  were  inoculated  with  syphilis  from  the  children;  through 
the  mothers,  the  disease  had  reached  some  of  the  husbands  and  even 
the  elder  children  of  the  different  families.  It  is  now  generally  believed 
that  vaccine  syphilis  is  only  spread  when  blood  is  admixed  with  the 
inoculated  lymph ;  that  pure  lymph  will  not  spread  syphilis  even  when 
taken  from  a  syphilized  child  ;  and  hence  that  vaccination  may  be  safely 
practised  in  some  cases  from  a  syphilized  child,  whilst  in  others  infec¬ 
tion  will  be  conve3^ed  when  blood  is  mixed  with  the  lymph. 

Progress. — The  consequences  of  contagion  are  hot  immediately 
manifested.  The  time  that  intervenes  between  inoculation  and  activity 
of  the  poison  is  called  the  incubation  pei'iod.  It  may  be  occupied  in 
three  wa^^s.  If  the  vehicle  containing  the  virus  be  of  a  non-irritating 
character,  the  broken  surface  heals,  and  all  trace  of  the  inoculation  dis¬ 
appears  until  the  incubation  is  completed;  or,  as  the  vehicle  of  the 
virus  is  often  pus  or  discharge  of  an  irritable  kind,  it  may  cause  imme¬ 
diate  inflammatory  action  at  the  point  of  inoculation.  This  irritation 
subsides  in  a  short  time,  and  the  part  then  remains  quiet  until  the  incu¬ 
bation  is  complete,  when  the  syphilitic  poison  betra^^s  its  presence  bj’’ 
characteristic  phenomena.  An  experiment  of  Yidal’s  illustrates  this : 
he  inoculated  the  matter  of  a  pustular  syphilitic  eruption  on  the  arm  of 
a  medical  student,  which  produced  a  pustule  in  a  couple  of  days  ;  this 
healed  over  in  about  a  fortnight,  and  the  experiment  was  supposed  to 
have  failed  until  the  thirty-fifth  day ;  action  then  recommenced  by  the 
development  of  a  papule,  which  subsequently-  ulcerated,  and  general 
sy^philis  followed  in  due  course.  If  the  syphilitic  virus  be  carried  in 
the  pus  of  a  local  contagious  chancre,  the  time  of  incubation  is  often 
occupied  by’’  the  course  of  a  chancre,  which  may  or  may  not  have  healed 
over  when  the  syphilitic  poison  begins  its  action.  This  series  of  events, 
first  a  suppurating  contagious  sore,  and  then  induration  forming  in  the 
base  of  the  sore,  or  in  its  scar  if  the  sore  have  already  healed,  is  per¬ 
haps  almost  as  common  as  the  inoculation  of  syphilis  unaccompanied 
by  immediate  local  irritation;  but  the  two  morbid  actions  have  no  con¬ 
nection  with  each  other,  and  are  only  accidentally  coexistent. 

The  length  of  this  time  of  inactivity  varies  in  different  persons  ;  it  is 
commonly  twenty-five  days.  The  shortest  known  period  before  the 
poison  began  to  reveal  its  presence  has  been  ten  days,  and  the  longest 
forty-six  days.  When  the  time  of  active  progress  has  arrived,  the 
point  of  contagion  becomes  an  elevated  hard  copper-colored  spot,  which 
sometimes  ulcerates,  and  if  irritated  does  so  freelyq  forming  the  indu¬ 
rated  or  Hunterian  chancre.  Not  unfrequently  the  surface  scarcely 
ulcerates,  but  is  simply  eroded  ;  and  even  erosion  may-  be  wanting, 
in  which  case  the  only  change  on  the  surface  is  simple  desquamation  of 
the  cuticle. 

The  Indurated  or  True  Hunterian  Chancre,  as  it  is  termed,  is 
not  by  any  means  so  frequently  met  with  as  the  other  manifestations  of 
syphilitic  inoculation.  The  great  characteristic  of  this  form  of  venereal 
ulcer  is  the  induration  of  its  edges  and  base ;  and  this  character  is  met 
with  from  the  very  first.  Any  ulcer,  but  more  especially  the  chan- 
crous  excoriation,  may  during  its  progress  become  indurated  from 
undue  stimulation,  or  from  being  otherwise  improperly  inflamed  ;  but 
the  Hunterian  chancre  is  indurated  from  the  very  first,  and  continues  so 
throughout.  This  induration  of  the  base  is  the  result  of  a  peculiar 
plastic  elfusion,  which,  though  it  microscopically  and  chemically^  resem- 


INDURATED  CHANCRE. 


699 


ble  ordinary  healthy  l3^mph,  ^^et  very  distinctly  differs  from  it  in  its  vital 
characters.  The  discharge  from  a  soft  chancre  consists  of  pus,  in  no 
way  distinguishable  b}"  the  microscope  from  the  pus  on  the  surface  of  a 
granulating  sore.  The  discharge  from  a  true  Hunterian  chancre,  when 
not  subject  to  any  undue  irritation,  consists  chiefly  of  epithelial  debris, 
floating  in  a  clear  fluid,  true  pus-cells  being  entirely  absent.  Besides 
the  presence  of  induration,  the  Hunterian  chancre  is  characterized  by 
its  circular  shape,  its  elevation  above  the  surrounding  parts,  and  the 
veiy  adherent  gray  slough  that  covers  its  surface.  It  is  usuall}^  seated 
on  the  glans ;  but  not  unfrequently  on  the  skin  of  the  prepuce,  or  of 
the  root  of  the  penis.  In  this  form  of  chancre  there  is  almost  invariably 
enlargement  of  the  l^’-mphatic  glands  in  the  groin. 

Seat  and  Number.  The  indurated  primary  ulcers  of  syphilis  are 
most  frequent  on  the  genitals.,  but  not  so  exclusively  limited  to  those 
parts  as  are  local  venereal  sores,  because  s^^philis  is  communicated  in 
various  ways  besides  that  of  sexual  intercourse,  and  thus  ma}^  appear  on 
any  part  of  the  body.  Fournier  found  that,  of  472  cases  of  inoculation 
in  men,  314  were  on  the  prepuce  and  glans  penis,  109  on  other  parts  of 
the  male  organ,  12  only  on  the  mouth,  6  on  the  hands  and  fingers,  and 
a  few  on  the  e^^elids,  tonsil,  and  navel. 

S3q3hilis  not  unfrequentl3'  occurs  amongst  Surgeons  and  accoucheurs 
as  a  consequence  of  inoculation  on  the  fingers.,  during  the  dressing  of  a 
venereal  sore,  or  the  delivery  of  a  diseased  woman  ;  and  is  also  occa¬ 
sionally  met  with  among  non-professional  people.  It  usually  appears  as 
a  small  sore  by  the  side  of  the  nail  and  under  its  matrix,  with  much 
swelling,  redness,  and  pain  in  the  finger,  which  becomes  bulbous  ;  pain 
and  swelling  of  the  axillary  glands  soon  follow.  If  the  nature  of  the 
disease  be  not  recognized,  the  ulceration  will  creep  round  the  tip  of  the 
finger,  have  a  foul  and  slougly  look,  with  exquisite  tenderness,  and, 
resisting  all  ordinary  treatment,  may  be  set  down  as  malignant;  on 
which  supposition  the  amputation  of  a  finger  ma3"  be  proposed  and 
practised.  I  have  seen  at  least  four  cases  in  which  this  extreme  measure 
has  been  proposed,  but  in  which  a  timely  discovery  of  the  true  nature 
of  the  afieetion  caused  the  finger  to  be  saved. 

In  some  cases  of  disgusting  depravit3^,  chancres  are  met  with  at  the 
margin  of  the  anus  and  on  the  lips  and  tongue.  These  are  alwa3^s  indu¬ 
rated;  and  from  their  foul  surface,  hard  base,  and  persistent  character, 
may  readily  be  mistaken  for  cancerous  affections.  Inoculation  will 
alwa3’s  test  this  point. 

Induration.  The  hardening  of  the  tissue  around  the  point  of  inocula¬ 
tion  varies  in  the  extent  to  which  it  is  developed.  It  is  best  developed 
in  the  skin,  where  it  takes  the  form  of  a  nodule  or  lump,  often  no  larger 
than  a  split  tea,  but  sometimes  as  large  as  a  walnut.  Now  and  then,  on 
the  thin  prepuce,  it  is  spread  widely  in  a  shallow  layer,  and  gives  the 
foreskin  the  “parchment  induration”  of  Ricord.  This  induration  re¬ 
mains  for  some  time  around  the  point  of  contagion,  usuall3^  two  or  three 
months,  though,  when  veiy  scantily  developed,  it  ma3''  vanish  in  a 
fortnight  or  three  weeks.  Ultimately  it  always  disappears  ;  though,  if 
irritated,  it  is  veiy  apt  to  break  down  into  obstinate  ulcers. 

It  is  maintained  by  man3'  Surgeons  of  great  authorit3^,  that  induration 
of  the  site  of  contagion  is  113"  no  means  a  constant  production.  The 
number  of  cases  where  induration  is  not  palpably  evident  is  very  small ; 
and,  though  probably  it  is  sometimes  wholly  wanting,  it  is  a  rare  excep¬ 
tion  for  it  to  be  so. 

Much  induration  is  often  thought  to  produce  a  severe  course  of 


700 


VENEREAL  DISEASES. 


syphilis,  and  probably  this  is  generally  true;  though,  and  especially 
■when  treatment  is  early  employed,  the  patient  often  escapes  all  sub¬ 
sequent  symptoms,  except  a  few  spots  on  the  skin  and  sore  throat. 

Indolent  Enlargement  of  the  Lymphatic  Glands.  The  so-called 
indolent  bubo  is  the  next  change  to  follow  induration  of  the  point  of 
contagion,  which  it  accompanies  or  very  closely  succeeds.  One  gland 
enlarges  first,  and  several  follow;  they  remain  painless  or  only  very 
slightly  tender;  the  skin  over  them  retains  its  natural  color  and  supple¬ 
ness,  and  there  is  no  doughy  thickness,  as  in  the  acute  suppurating 
bubo.  In  this  state  the  glands,  nevertheless,  not  unfrequently  suppu¬ 
rate,  and  an  abscess  forms  around  them.  This  accident  is  generally  set 
up  by  violent  exertion,  such  as  dancing,  riding,  and  the  like;  but  it  has 
no  special  significance — it  never  yields  a  specific  inoculable  pus  like  the 
virulent  bubo  of  the  local  chancre.  The  anatomical  chanore  in  the 
glands  themselves  consists  in  congestion  and  the  deposit  of  irregular 
fibro-plastic  lymph,  which  produces  their  increased  size.  If  the  point 
of  contagion  be  seated  near  the  middle  line,  at  the  frsenum  for  instance, 
the  glands  in  both  groins  are  often  enlarged. 

In  weakly  persons,  the  glands  throughout  the  body  become  enlarged; 
those  at  the  back  of  the  neck,  especially,  are  very  commonly  enlarged 
during  the  time  of  the  eruption  on  the  skin,  and  those  of  the  axilla  and 
other  parts  are  sometimes  included  in  the  enlargement.  This  condition 
of  the  glands  is  accompanied  by  a  great  increase  in  the  proportion  of 
colorless  corpuscles  in  the  blood ;  but  both  these  alterations  of  the 
lymphatic  system  are  temporary,  and  disappear  spontaneously  in  a 
short  time. 

Treatment. — Local  Treatment.,  while  of  much  value  in  the  non¬ 
syphilitic  venereal  sore,  is  of  little  or  no  avail  in  the  disease  now  under 
consideration ;  the  causes  of  the  local  manifestations  being  beyond  the 
reach  of  any  direct  application.  The  treatment  must  be  directed  to  the 
neutralization  of  the  action  of  the  poison,  and  its  removal  from  the 
constitution,  by  remedies  given  so  as  to  act  generally  on  the  system. 

The  Constitutional  Treatment  of  primaiy  syphilis  has  undergone 
various  changes  according  to  the  prevailing  doctrine  of  the  day.  It 
had  been  decided  by  the  Surgeons  of  the  last  and  early  part  of  this 
century,  that  mercury  acted  as  a  specific  against  the  syphilitic  poison. 
This  doctrine  was  so  firmly  established,  that  Hunter,  and  many  of  the 
great  Surgeons  of  his  school,  looked  on  the  curability  of  a  sore  without 
mercury  as  a  proof  that  it  was  not  syphilitic. 

About  the  commencement  of  this  century,  however,  it  was  found  by 
observations  of  the  Arm3’-Surgeons,  amongst  whom  Rose  took  a  princi¬ 
pal  share  in  the  inquiry,  that  the  difterent  forms  of  venereal  ulcer,  no 
distinction  being  then  drawn  between  the  local  non-infecting  sores 
and  the  ulcers  which  resulted  from  the  contagion  of  the  constitutional 
disease,  were  curable  without  the  necessity  of  administering  mercury,  or 
indeed  of  having  recourse  to  any  specific  treatment  whatever. 

These  observations,  which  appear  to  be  founded  on  what  was  wit¬ 
nessed  in  Spain  and  Portugal  during  the  Peninsular  War,  led  to  the 
introduction  of  an  important  modification  in  the  treatment  of  venereal 
sores ;  viz.,  the  non-mercurial  or  simple  plan,  as  it  is  termed ;  a  mode 
of  practice  that  obtained  great  favor,  and  has  been  extensively  tried. 
Of  late  years,  however,  a  reaction  has  taken  place  in  the  minds  of  most 
professional  men,  and  mercury  is  again  employed  in  the  treatment  of 
this  disease,  but  more  moderately  and  scientifically,  and  consequently 
more  successfully  than  before. 


MERCUEY  IN  PRIMARY  SYPHILIS. 


701 


The  arguments  in  the  favor  of  the  non-mercurial  plan  of  treatment 
are  briefly  these:  that  by  this  system  of  treatment  the  constitution  of 
the  patient  is  saved  the  introduction  of  a  mineral  which  in  many  cases 
acts  injuriously,  and  w’hich,  as  the  disease  can  be  cured  without  it,  may 
at  all  events  be  looked  upon  as  unnecessary ;  that  secondary  affections 
less  frequently  follow  this  plan  than  the}^  do  the  administration  of  mer¬ 
cury ;  and,  lastly,  that  those  distressing  cases  of  constitutional  syphilis 
which  are  common  after  mercurial  courses,  and  which  are  said  to  depend 
upon  a  peculiar  combination  of  the  syphilitic  poison  and  the  mineral  in 
the  system,  are  never  met  with  in  persons  who  have  undergone  the 
simple  treatment.  These  arguments,  however,  on  closer  examination 
and  further  experience,  have  been  proved  to  be  not  quite  so  conclusive 
as  the  supporters  of  the  simple  treatment  appear  to  believe.  That  a 
great  number,  perhaps  the  majority’',  of  cases  of  simple  soft  chancre, 
which  we  now*  know  to  be  an  affection  of  a  totally  distinct  nature  from 
syphilis,  can  be  healed  without  the  administration  of  mercury,  is  un¬ 
doubtedly  the  fact ;  but  it  is  equally  true  in  many  instances  that  the 
indurated  sore  does  not  cicatrize  properly  unless  the  mineral  be  admin¬ 
istered,  or,  if  it  do  close,  that  it  heals  in  an  imperfect  manner,  readily 
breaking  out  again.  But  it  is  a  most  serious  error  to  confound  the 
healing  of  ulcers  with  the  cure  of  syphilis.  The  cicatrization  of  an  ulcer 
and  neutralization  of  the  constitutional  affection  are  two  distinct  things  ; 
and  the  test  of  the  relative  value  of  these  two  plans  of  treatment  must 
depend  rather  on  the  influence  the}"  have  over  the  course  of  syphilis, 
and  on  the  character  that  the  symptoms  assume  under  one  or  other  of 
these  methods,  than  on  the  mere  skinning  over  of  the  ulcer.  I  cannot 
agree  ■with  the  statement  that  secondary  symptoms  are  less  frequent 
after  the  simple  than  after  the  mercurial  treatment  of  syphilis.  I  have 
seen  the  non-murcurial  plan  of  treatment  very  extensively  employed  at 
LTniversity  College  Hospital ;  indeed,  it  was  formerly  almost  invariably 
practised  there,  more  particularly  in  the  syphilitic  cases  occurring 
among  the  out-patients  under  Morton,  who  strongly  advocated  it ;  and 
I  have  had  repeated  occasion  to  observe  the  frequency  with  which  it 
was  followed  by  secondary  symptoms.  In  private  practice,  also,  I  have 
had  considerable  opportunities  of  comparing  the  two  methods ;  and  I 
can  safely  say  that  I  have  seen  the  simple  treatment  more  frequently 
followed  by  secondary  symptoms  than  the  mercurial  plan  has  been, 
when  properly  and  judiciously  employed.  The  supporters  of  the  non¬ 
mercurial  treatment,  when  obliged  to  admit  the  great  frequency  with 
which  it  is  followed  by  secondary  symptoms,  argue  that  these,  if  more 
frequent,  are  less  severe  after  the  simple  than  after  the  mercurial  plan; 
and  they  state  somewhat  dogmatically,  and  it  appears  to  me  without 
any  evidence  to  support  their  statement,  that  mercury  and  syphilis 
together  form  a  sort  of  poisonous  compound  in  the  system,  which  pro¬ 
duces  the  worst  and  most  destructive  forms  of  constitutional  syphilis. 
I  deny  entirely,  that  we  have  any  proof  of  the  existence  of  such  a  com¬ 
bination  as  that  which  is  supposed  to  be  produced  by  syphilis  and 
mercury;  no  evidence  with  which  I  am  acquainted  has  ever  been  ad¬ 
duced  in  support  of  the  formation  of  such  a  poison  in  the  system.  It 
is  doubtless  true  that,  after  an  ill-regulated  mercurial  course,  constitu¬ 
tional  syphilis  of  a  very  severe  character  may  occasionally  appear ;'  but 
this  seems  to  me  to  be  rather  owing  to  mercury  having  been  improperly 
administered  in  constitutions  that  will  not  bear  it,  and  in  which,  by  the 
induction  of  a  cachectic  and  depraved  condition  of  the  system,  it  favors 
the  occurrence  of  some  of  the  more  severe  forms  of  secondary  syphilis. 


702 


VEXEREAL  DISEASES. 


in  the  same  way  that  any  other  lowering  plan  of  treatment,  or  simple 
debility,  might  occasion  them,  but  without  the  exercise  of  any  specifi- 
call}’  injurious  influence.  Some  of  the  worst  forms  of  constitutional 
sj'philis  that  I  have  seen,  occurred  in  patients  to  whom  no  mercury  had 
been  administered,  but  in  whom  the  syphilitic  virus  had  been  allowed  to 
exercise  its  influence  unchecked,  save  by  the  so-called  simple  treatment. 
I  have  seen  the  body  covered  b}^  immense  ecthymatous  crusts  and  sores 
in  one  case,  rupial  ulcers  with  destruction  of  the  nose  and  palate  in 
another,  the  worst  kind  of  sj’philitic  cachexy  with  the  tuberculo-pustular 
syphilide  in  a  third,  and  extensive  disease  of  the  cranial  bones  and  the 
clavicle  in  a  fourth ;  in  none  of  which  had  any  mercury  been  admin¬ 
istered. 

But,  though  I  cannot  admit  that  the  supporters  of  the  simple  or  non¬ 
mercurial  treatment  of  sj'philis  have  brought  forward  any  proof  of  its 
superiority  over  the  mercurial  plan,  and  though  my  own  experience  has 
taught  me  that  secondary  s3^mptoms  occur  after  it  with  no  less  severity, 
and  with  far  greater  frequency  than  they  do  when  mercury  is  carefully 
and  judiciousl}'  administered,  3^et  I  am  quite  ready  to  allow  that  there 
are  certain  conditions  of  sjq^hilis  in  which  the  non-mercurial  treatment 
alone  is  admissible,  the  state  of  the  constitution  or  the  disease  being 
such  that  mercury  cannot  be  given  in  any  form.  In  these  cases  such  a 
treatment  must  be  adopted,  in  accordance  with  ordinaiy  medical  prin¬ 
ciples,  as  will  tend  to  subdue  local  action  and  improve  the  general  con¬ 
dition.  It  is,  indeed,  especially’  in  individuals  of  an  unhealthy’  or  stru¬ 
mous  habit  of  body,  or  in  those  who  are  suffering  from  local  visceral 
disease  of  some  kind,  and  who  are  not  affected  by  an  indurated  chancre, 
that  this  plan  of  treatment  should  be  adopted.  So  also  in  those  who, 
from  the  nature  of  their  occupations,  are  subjected  to  much  exposure 
to  wet  and  cold,  a  mercurial  course  cannot  be  properly  or  safely 
administered,  and  the  simple  treatment  is  the  most  advisable  plan  that 
should  be  adopted.  But  even  in  such  individuals  mercury  is  often 
necessary  to  destroy  the  activity  of  the  disease.  In  all  other  cases,  I 
am  certainly  of  opinion  that  mercury’  ought  to  be  administered;  and 
this  opinion  appears  to  be  entertained  by  the  most  experienced  Surgeons 
of  the  day’  in  this  country’  and  abroad. 

The  first  question  in  connection  with  the  employ’ment  of  mercury  in 
syphilis  has  reference  to  the  principle  on  which  this  remedy’’  is  adminis¬ 
tered.  Whether  mercuiy  exercises  a  specific  action  over  the  poison  of 
sy’philis,  or  not,  has  been  much  discussed,  and  is  difficult  of  proof.  I 
am  certainly"  of  opinion  that  it  does  act  as  a  specific  in  syphilis,  but  that 
this  specific  action  is  much  influenced  by’  the  condition  of  the  sy^stem, 
the  habits  of  the  patient,  and  the  mode  of  administering  the  remedy’ ; 
these  conditions  under  certain  circumstances  tending  to  counteract  or 
otherwise  to  interfere  with  its  operation.  That  mercury  in  many  cases 
is  antagonistic  to  the  syphilitic  poison,  appears  evident  from  the  fact 
that  in  some  instances  hard  ulcers  will  not  heal  unless  it  be  given  inter¬ 
nally"  ;  from  its  influence  in  speedily  curing  infantile  sy’philis  and  pre¬ 
venting  after-manifestations  in  the  sy’stem  ;  and  from  the  fact  that,  when 
properly’  administered  in  healthy  constitutions^  it  may’  almost  to  a  cer¬ 
tainty’  be  expected  to  dissipate  the  various  sy’mptoms  of  constitutional 
syphilis.  When  it  fails,  as  it  doubtless  does  in  many’  cases,  to  prevent 
the  constitutional  infection,  or  to  eradicate  this  if  it  have  appeared,  the 
failure  may’  usually’  be  traced  either  to  want  of  care  in  the  administration 
of  the  medicine,  or  to  the  existence  of  an  impaired  state  of  the  patient’s 


MODE  OF  ADMINISTERING  MERCURY. 


703 


health  ;  though  doubtless,  in  some  cases,  the  most  judicious  emplo3^ment 
of  mercuiy  is  unsuccessful  in  arresting  the  progress  of  s^^^hilis. 

In  connection  with  the  administration  of  mercur}^  in  syphilis,  there¬ 
fore,  various  questions  present  themselves,  the  proper  determination  of 
which  is  of  the  first  importance.  These  have  reference  to  the  State  of 
the  Patient’s  Constitution,  the  Condition  of  the  Sore,  and  the  Mode  of 
Administration  of  the  Remedy. 

The  Slate  of  the  PatienVs  Constitution  influences  materially  the  pro- 
priet3^  of  the  administration  of  mercury.  In  ordinaiy  healthy  constitu¬ 
tions,  it  ma3'’  alwa3"s  be  safely  emplo3’ed ;  but,  if  the  powers  of  the  S3's- 
tem  have  been  broken  b3"  excesses  of  an3^  kind,  if  the  patient  be  of  a 
strumous  habit  of  bod3’',  if  he  be  irritable,  feverisli,  or  excited,  it  must 
be  given  with  great  caution,  or  should  be  withheld  until  these  states  of 
the  S3’stem  are  modified  or  removed.  It  is  especially  b3^  administering 
mercury  to  strumous  and  cachectic  patients,  or  to  those  whose  powers 
have  been  broken  by  habitual  dissipation,  that  so  much  mischief  results; 
and  that  it  occasionally  gives  rise,  by  acting  as  a  depressing  agent,  to 
local  sloughing,  or  to  some  of  the  low  forms  of  secondary  S3q3hilis. 

3Iode  of  Administering  Mercury.  The  particular  preparation  of 
mercury  to  be  given,  the  length  of  time  during  which  it  should  be  con¬ 
tinued,  and  the  rules  to  he  observed  during  the  mercurial  course,  are  all 
matters  that  influence  greatl3^  the  result  of  the  treatment. 

Mercuiy  may  be  administered  in  four  wa3^s :  by  the  mouth,  by  inunc¬ 
tion,  by  subcutaneous  injection,  or  by  fumigation.  When  it  is  to  be 
given  b3’  the  mouth  in  early  syphilis,  and  when  it  is  desirable  to  produce 
but  a  moderate  efiect  upon  the  S3’stem,  I  prefer  the  iodide  of  mercuiy, 
in  doses  of  one  grain  three  times  a  day  ;  or  the  Plummer’s  pill,  in  five- 
gi’ain  doses  twice  or  three  times  a  da3'’,  will  be  found  extremel3’  useful 
when  the  constitution  is  somewhat  irritable.  If  it  be  desirable  to  pro¬ 
duce  a  rapid  effect  upon  the  system,  five  grains  of  blue  pill  ma3^  be  given 
night  and  morning.  The  other  preparations  of  mercury  are  not,  I  think, 
required  in  the  primary  form  of  the  disease.  When  it  is  required  to 
produce  a  moderate  effect,  especiall3’-  in  somewhat  delicate  persons, 
without  irritating  the  system  or  inducing  much  salivation,  the  iodide  is 
certainly  to  be  preferred  to  all  other  preparations. 

In  some  cases  the  bowels  are  so  irritable  that  the  administration  of 
mercuiy  b3"  the  mouth  invariabl3^  purges  the  patient ;  in  these  circum¬ 
stances,  the  mercurial  inunction  ma3^  be  conveniently  practised.  This 
is  best  done  b3^  rubbing  a  drachm  of  the  strong  ointment  into  the  inside 
of  each  thigh  for  ten  minutes  every  night  and  morning ;  or  b3^  putting  a 
similar  quantity  upon  a  piece  of  lint,  and  letting  the  patient  wear  it 
during  the  da3^  and  night  in  each  axilla.  It  must  be  borne  in  mind  that 
the  orifices  of  the  sweat-glands  and  hair-follicles  become  filled  with  the 
ointment ;  so  that,  should  salivation  commence,  it  is  impossible  at  once 
to  arrest  the  absorption  of  the  mercury. 

The  duration  of  the  mercurial  course  must  depend  upon  the  effect  pro¬ 
duced  upon  the  sore.  The  course  need  not  be  continued  until  this  has  cica¬ 
trized,  but  should  be  persevered  in  until  all  specific  action  has  ceased,  and 
the  sore  has  acquired  a  healtly^  and  healing  state.  This  impression  is  sel¬ 
dom  produced  upon  the  sore,  wdthout  a  slight  effect  upon  the  mouth  having 
been  previously  induced  ;  the  gums  becoming  spongy,  red,  and  swollen, 
and  an  increased  flow  of  saliva  taking  place.  It  is  never  necessaiy  to 
continue  the  mercuiy  so  long,  or  to  give  it  to  so  great  an  extent,  as  to 
produce  very  profuse  salivation.  It  was  in  attempting  to  do  this,  and  by 


70-i 


TEXEREAL  DISEASES. 


administering  the  remedy  in  too  large  a  quantity,  and  too  rapidlj^,  that 
the  older  Surgeons  produced  such  injurious  consequences.  The  effect 
upon  the  sore,  rather  than  that  upon  the  gums,  should  be  our  guide  as  to 
the  proper  time  for  discontinuing  the  mercurial. 

The  rules  to  be  observed  during  a  course  of  mercury  exercise  con¬ 
siderable  influence  upon  the  effects  produced  by  it.  The  system  should 
always  be  prepared  for  its  administration  by  a  free  purge.  While  it  is 
being  given,  the  patient  should,  if  possible,  be  kept  in.  bed,  or  at  all 
events  be  confined  to  the  house,  taking  as  much  rest  as  possible ;  the 
diet  should  be  moderate  and  unstimulating,  and  the  dress  be  as  warm  as 
the  season  will  admit.  If  the  mercury  be  given  by  the  mouth,  and 
gripe,  it  will  be  found  useful  to  combine  it  with  capsicum.  If  it  purge, 
small  doses  of  opium  may  advantage  on  si}'  be  administered  in  conjunc¬ 
tion  with  it.  After  it  has  been  carried  to  the  full  extent  deemed  advisa¬ 
ble,  it  should  not  be  suddenly  left  off,  but  gradually  discontinued  by 
diminishing  the  quantity  daily  during  a  week  or  ten  days.  If  it  be  given 
in  accordance  with  these  rules,  and  in  proper  constitutions,  we  shall 
seldom  find  any  of  those  injurious  effects  produced  that  were  formerly 
described  as  resulting  from  the  administration  of  this  mineral ;  those 
severe  and  extensive  forms  of  ulceration  of  the  mouth,  leading  to  necrosis 
of  the  jaws,  and  the  mercurial  er3Thema  or  erethismus  described  by  the 
older  Surgeons,  are  now  happily  almost  matters  of  histor}-,  being  but 
seldom  if  ever  met  with. 

SECONDARY  OR  CONSTITUTIONAL  MANIFESTATIONS  OF 

SYPHILIS. 

The  introduction  of  the  S5’philitic  poison  into  the  general  sj^stem  gives 
rise  to  two  veiy  important  groups  of  phenomena  :  first,  those  that  affect 
the  S3^stem  geuerall}’’,  infiuencing  deepl}-  the  condition  of  the  blood  and 
the  nutrition  of  all  the  textures  of  the  bod}",  occasioning  febrile  dis¬ 
turbance,  followed  by  emaciation,  cachexy,  and  general  evidences  of 
malnutrition :  secondl}",  a  variet}"  of  local  diseases,  which  are  charac¬ 
terized  b}"  distinct  phenomena ;  1.  ^Modification  of  the  epidermis  and 

epithelium,  as  observed  in  mucous  tubercles,  psoriasis,  and  analogous 
affections,  and  ulcerations,  affecting  the  skin  and  mucous  meinbranes  in 
various  parts  of  the  bod}" ;  2.  The  deposit  of  lowly  organized  lymph  in 
various  tissues  and  organs,  as  the  periosteum,  the  iris,  testes,  Ac. 

The  period  at  which  syphilitic  eruptions  appear  usually  varies  from 
six  weeks  to  six  months  after  the  formation  of  the  indurated  sore. 
Occasionally  secondary  syphilis  shows  itself  earlier,  about  the  second 
or  third  week,  when  it  may  be  coincident  with  the  existence  of  primary 
syphilis.  Most  commonly  its  symptoms  are  progressive — the  milder, 
such  as  the  affection  of  the  skin  and  mucous  membrane,  occurring 
first ;  the  more  severe,  as  those  of  the  bones  and  organs,  afterwards : 
but  in  other  cases  this  progression  is  not  observed,  symptoms  of  great 
intensity  setting  in  early,  without  being  preceded  by  those  of  a  slighter 
kind. 

It  is  extremely  difficult  to  say  when  syphilis  can  be  eradicated  from 
the  system  ;  and  indeed  it  is  a  question  whether  it  may  not  impress 
the  constitution  in  a  peculiar  way,  modifying  certain  actions  during  the 
rest  of  life,  as  we  know  to  be  the  case  in  other  specific  diseases,  such  as 
cow-pox  or  scarlet  fever.  Certain  it  is  that,  if  neglected  or  improperly 
treated,  it  will  affect  the  system  for  an  indefinite  time,  declaring  its 
existence  by  exciting  and  modifying  various  local  inflammations  years 


SECONDARY  OR  CONSTITUTIONAL  SYPHILIS.  705 

after  the  original  absorption  of  the  poison.  It  is,  tolerably  clear  that  a 
person  who  has  once  had  the  usual  course  of  syphilis  and  has  recovered 
from  his  malady,  cannot  have  it  a  second  time,  though  he  contract  a 
fresh  chancre  ;  and  E.  Wilson  attributes  maii}^  of  the  ordinaiy  non¬ 
specific  cutaneous  diseases  to  the  latent  influence  of  constitutional 
s^qohilis.  This  rule  is  from  time  to  time  proved  to  be  genei’all}’-  true  by 
the  occasional  observation  of  undoubted  exceptions,  where  repetition 
of  the  disease  from  re-inoculation  of  the  virus  takes  place.  But  such 
cases  are  exceeding!}^  rare,  and  occur  only  after  an  interval  of  some 
years  has  elapsed  between  the  two  attacks.  Hutchinson  has  related  a 
very  interesting  example  of  this  kind  in  a  medical  student,  who  also 
suftered  two  attacks  of  smallpox.  Daily  experience  shows  that  in 
many  constitutions  syphilis  cannot  be  eradicated,  and  that  in  most 
others,  when  once  it  has  occurred,  it  is  apt,  even  when  apparently 
cured,  to  modify  certain  cutaneous  and  other  aflections  in  a  remark¬ 
able  manner,  after  a  lapse  of  many  years ;  showing  clearly  that,  if  the 
poison  no  longer  exist  in  the  system,  the  constitution  has  received  a 
peculiar  impress  from  it,  which  it  is  long  in  losing.  These  remote 
effects  of  syphilis  have  by  Ricord  been  called  Tertiary.  This  term  is 
convenient  as  indicating  a  peculiar  stage  of  the  constitutional  mani¬ 
festations,  in  which  the  tissues  are  more  deeply  affected  than  in  the 
secondary  forms  of  the  disease. 

Although  the  disease  may  continue  to  modify  the  system  for  years, 
or  even  for  life,  yet  it  seldom  proves  fatal.  In  some  cases,  however, 
death  may  occur,  either  by  the  cachexy  that  is  induced,  by  the  super¬ 
vention  of  phthisis,  or  by  caries  of  the  skull  or  nodes  of  the  dura 
matter,  and  consequent  disease  of  the  brain.  Fatal  and  specific  syphil¬ 
itic  diseases  of  the  lungs  and  brain  have  been  described  of  late  years 
with  much  care,  though  there  still  remains  a  good  deal  to  be  ascer¬ 
tained  of  the  relation  of  S3q)hilis  to  these  changes  in  the  brain  and 
other  viscera. 

It  is  especially  when  the  disease  has  reached  the  tertiary  stage,  that 
it  runs  so  protracted  and  tedious  a  course.  When  the  syphilitic  ma¬ 
nifestations  are  confined  to  affections  of  the  cutaneous  and  mucous 
surfaces,  the  disease  may,  and  does  occasionally,  wear  itself  out — the 
materies  inorhi  being  apparently  carried  oft*  by  the  secretions  of  these 
tissues  ;  and  it  is  only  in  this  way,  I  believe,  that  the  affection  can  be 
eradicated  from  the  system. 

That  constitutional  syphilis  is  dependent  on  the  absorption  of  the 
syphilitic  poison  into  the  blood,  and  its  consequent  general  diffusion 
through  the  system,  there  can  be  little  doubt.  Not  only  is  this  ren¬ 
dered  evident  by  the  great  variety  of  tissues  and  organs  in  which  it 
manifests  itself  locally,  but  also  in  the  induction  of  the  peculiar  syphil¬ 
itic  cachex}^ 

Phenomena. — Constitutional  sjqDhilis  may  afl*ect  the  following  tis¬ 
sues  and  organs,  and  usually  does  so  in  the  order  in  which  they  are  men¬ 
tioned  :  viz.,  the  skin,  mucous  membranes,  periosteum,  and  bones ;  the 
throat,  tonsils,  palate,  eyes,  nose,  larynx,  tongue,  and  testes. 

The  first  general  disturbance  of  s^’philis  is  often  ushered  in  by 
febrile  S3"mptoms.  In  proportion  to  the  severity  of  these  are  usuall}’- 
the  rapidity  of  the  progress  and  the  extent  of  the  local  manifestations. 
In  this  febrile  disturbance,  the  nutrition  of  all  the  tissues  of  the  body 
becomes  seriously  impaired,  and  the  patient  acquires  a  peculiar  cachectic 
look.  In  other  cases  the  patient  gradually  falls  into  a  feeble  and  ema- 
VOL.  I. — 45 


706 


VENEREAL  DISEASES. 


ciated  condition  becoming  sallow  and  earthj’-looking,  with  loss  of  hair, 
and  depression  of  mental  and  bodil}’  vigor.  In  this  condition  not  only 
are  the  nutritive  functions  impaired,  as  is  evidenced  by  his  becoming 
weak  and  thin,  but  the  reparative  actions  are  lessened,  wounds  do  not 
heal  kindl}’,  and  fractures  are  slow  in  uniting. 

The  syphilitic  affections  occurring  on  the  skin  and  mucous  membranes 
are  usuallj^  a  secondaiy,  though  some  belong  to  the  tertiaiy  group;  whilst 
those  of  the  bones  and  different  organs,  as  the  larynx  and  testes,  are 
commonly  tertiary.  Although  the  integumental  structures  are  usually 
first  affected,  3^et  sometimes  the  disease  first  attracts  attention  by  its  at¬ 
tacks  upon  the  deeper  and  more  important  tissues,  the  S3’mptoms  of 
its  progress  on  the  skin  and  mucous  membranes  having  been  entirely 
overlooked.  In  women,  it  is  constantl3"  the  case  for  the  eruptive  stage 
to  be  confined  to  a  few  mucous  patches  of  the  vulva  and  excoriations  of 
the  fauces,  the  former  01113"  of  which  are  sufl[icientl3"  anno3"ing  to  attract 
the  patient’s  attention. 

Circumstances  influencing  Progress. — The  severit3"  and  mani¬ 
festations  of  general  disorder  which  follow  the  contagion  are  very  vari¬ 
ous  ;  thus,  a  widel3"  and  long  indurated  ulcer  foretells  with  few  exceptions 
a  long  and  severe  course  of  S3’philis ;  so,  also,  a  short  interval  between 
the  appearance  of  the  s3"mptoms  of  general  disorder  at  the  point  of  con- 
taoion  will  also  indicate  a  severe  course  of  the  disease,  and  a  loiio;  inter- 
val  a  mild  course  of  the  after-consequences. 

That  the  treatment  of  the  'primary  sore  exercises  considerable  influence, 
cannot  be  doubted.  The  severit3"  of  the  course  of  S3qihilis  is,  I  believe, 
materialh"  lessened,  and  not  in  aiy^  wa3^  increased,  b3"  a  mercurial  course, 
if  that  course  be  properl3'  conducted. 

The  state  of  the  patienVs  health  also  greatl3"  determines  the  kind  of 
attack  he  will  have  to  undergo.  If,  after  the  cure  of  the  primaiy  disease, 
his  health  continue  good,  he  ma3'  almost  wholl3’  escape  further  S3"mptoms 
of  the  disease ;  but  if  it  be  broken  or  cachectic,  then  secondary  S3"philis 
will  occur  contemporaneousl3"  with,  or  at  a  veiy  earl3'  period  after,  the 
primaiy  disease ;  and,  indeed,  I  general]3"  look  upon  the  chance  of  the 
speed3"  supervention  of  secondaiy  S3'philis  as  more  immediatehulependent 
on  this  than  on  aiy^  other  cause.  It  is  remarkable  for  how  long  a  time 
the  S3'philitic  poison  will  continue  dormant  in  the  constitution  w'ithout 
producing  an3"  local  manifestation  of  its  existence,  until  this  is  developed 
under  the  influence  of  a  broken  state  of  health.  I  have  had  under  m3" 
care  an  extremel3'  severe  case  of  constitutional  S3"philis,  in  which  twelve 
3"ears  elapsed  since  the  occurrence  of  the  primaiy  disease,  during  the 
whole  of  which  time  no  secondaiy  affection  was  observed  until  the 
patient’s  health  gave  wa3^  from  other  causes.  And  I  have  also  had 
under  m3"  care  an  officer,  in  whom  a  A’eiy  severe  form  of  constitutional 
syphilis  occurred,  for  the  first  time,  after  salivation  for  hepatic  disease, 
five  3’ear^  after  the  primaiy  sore  had  been  contracted — no  constitutional 
manifestation  having  attracted  the  patient’s  notice  in  the  mean  while. 
Not  only  does  a  state  of  ill  health  hasten  the  occurrence  of  secondary 
S3"philis,  but  cachex3',  neglect,  or  indifference  to  its  existence  may  keep  it 
up  indefinitel3\ 

The  question  as  to  there  being  an3"  connection  between  the  nature  of 
the  primary  sore^  and  the  character  of  the  consecutive  constitutional 
affection,  has  been  much  discussed  ;  and  I  agree  with  Carmichael,  that 
the  different  forms  of  primary  sore  will,  if  left  to  themselves,  be  followed 
each  by  its  own  peculiar  train  of  constitutional  s3’mptoms.  In  fact  I 
am  full3'  convinced,  as  the  result  of  much  and  close  observation  on  this 


TREATMENT  OF  CONSTITUTIONAL  SYPHILIS. 


707 


point,  tliat  there  is  a  general  correspondence  between  the  kind  of  ulcer 
and  the  manifestations  of  constitutional  s^'philis  that  may  follow  it ;  both, 
in  fact,  being  chiefly  dependent  upon  the  state  of  the  patient’s  health. 
The  same  condition  of  system,  for  instance,  that  will  occasion  a  local 
chancre  to  assume  the  phagedenic  or  sloughing  form,  will  occasion  rupia 
or  ecth3una,  with  necrosis  or  caries  of  the  bones,  as  the  constitutional 
manifestations  of  s\’philis ;  whereas  that  which  occasions  the  indurated 
chancre  will  equally  modif}^  the  secondaiy  disease,  so  that  it  assumes  a 
squamous  form,  accompanied  perhaps  by  iritis  and  periosteal  disease;  and 
the  soft  or  excoriated  chancre  will  generall}^  be  followed  by  papular  or 
roseolar  eruptions,  with  mucous  tubercles  on  the  tongue  or  throat.  That 
these  sequences  are  of  veiy  frequent  occurrence  I  cannot  doubt,  having 
frequentl}"  observed  them  ;  and  that  they  are  not  of  constant  occurrence 
is,  I  believe,  owing  to  the  character  of  the  constitutional  atfection  being 
modified,  b}’’  the  state  of  the  patient’s  health  having  undergone  a  change 
subsequent!}’  to  the  cure  of  the  primary  sore,  or  to  the  patient  not 
having  been  infected  with  syphilis  when  he  contracted  the  local  sore, 
and  having  thus  not  been  rendered  liable  to  constitutional  infection.  A 
patient  having  indurated  chancre  will  usually  get  psoriasis  as  the 
secondary  cutaneous  disease ;  but,  if  he  fall  into  a  cachectic  state  of 
health  between  the  healing  of  the  chancre  and  the  supervention  of  the 
constitutional  affection,  rupia  will  manifest  itself. 

Treatment. — In  the  treatment  of  constitutional  syphilis,  our  object 
is  not  so  much  to  relieve  or  to  remove  any  local  morbid  condition,  as  to 
eradicate  a  poison  from  the  system;  and,  indeed,  the  various  lochl  mani¬ 
festations,  more  especially  those  that  appear  upon  the  cutaneous  and 
mucous  surfaces,  may  possibly  be  eftbrts  of  nature  for  the  elimination 
of  the  virus  from  the  system  through  the  medium  of  the  great  excretory 
and  emunctory  organs ;  and  it  is  often  apparently  by  aiding  this  natural 
action  by  the  administration  of  those  remedies  that  act  upon  these  tis¬ 
sues,  that  the  poison  is  most  effectually  eradicated. 

During  the  continuance  of  the  pyrexia  which  often  ushers  in  the 
secondary  symptoms,  little  can  be  done  in  the  way  of  specific  means  for 
the  removal  of  the  disease  from  the  system ;  rest  and  mild  antiphlogistic 
treatment  being  all  that  can  be  accomplished  during  this,  the  stage  of 
invasion  and  of  constitutional  reaction.  Great  relief  is,  however, 
afforded  by  a  few  doses  of  mercury  given  so  as  to  affect  the  system. 
At  a  later  period,  when  the  cachexy  which  is  attendant  on  the  disease 
has  declared  itself,  attention  to  the  hygienic  and  dietetic  management 
of  the  patient  is  of  the  utmost  importance ;  a  light  nourishing  diet,  often 
accompanied  by  the  moderate  use  of  wine  or  beer,  and,  in  some  of  the 
lower  forms  of  syphilis  in  broken  constitutions,  a  general  tonic  plan  of 
treatment,  such  as  the  administration  of  bark,  quinine,  or  iron,  and  more 
especially  of  cod-liver  oil,  with  the  mineral  acids  and  sarsaparilla,  are 
required  in  combination  Avith  the  more  specific  means  that  we  possess  for 
the  eradication  of  the  disease  from  the  system.  These  -hygienic  and 
tonic  remedies  must  be  administered  in  accordance  with  general  medical 
principles,  and  no  special  instructions  need  consequently  be  laid  down 
for  their  use  here. 

The  treatment  of  syphilis  is  conducted  on  one  of  these  principles: 
1,  by  the  administration  of  mercury  with  the  view  of  directly  and  spe¬ 
cifically  eliminating  the  poison  from  the  system;  2,  by  the  preparations 
of  iodine,  which  are  supposed  to  be  specific  in  a  minor  degree  than  mer¬ 
cury  in  this  disease ;  and  3,  by  simple  attention  to  the  state  of  the  gene¬ 
ral  health,  without  any  attempt  at  specific  treatment.  These  difierent 


708 


VENEREAL  DISEASES. 


principles  may  be  employed  simultaneously  or  consecutively.  As  a 
general  rule  it  may  be  stated  that,  the  longer  the  interval  that  separates 
the  constitutional  from  the  primary  symptoms,  the  more  they  partake  of 
a  tertiary  character,  the  less  necessity  will  there  be  for  specific  treatment, 
and  the  more  important  will  be  the  employment  of  all  means  calculated 
to  improve  the  health. 

Of  the  value  of  mercury  in  constitutional  s^q^hilis,  every  Surgeon  of 
experience  must  have  had  abundant  proof.  It  may  admit  of  doubt 
whether  mercury  can  be  justly  considered  as  exercising  a  specific  action, 
as  there  are  some  cases  of  the  disease  that  it  certainly  does  not  appear 
to  influence  in  a  beneficial  manner,  and  others  the  severity  of  which  is 
certainl}^  increased  by  the  administration  of  this  remedy;  but  it  appears 
to  me  that  in  these  cases  it  is  rather  the  patient’s  constitution,  which  does 
not  bear  the  remedy  well,  than  the  disease  that  is  at  fault.  We  know  that  in 
man}^  states  of  the  S3’stem,  and  in  man}"  individuals  unaffected  b}"  syphilis, 
mercuiy  acts  injuriousl}",  more  especially  when  aiy^thing  like  cachexy  is 
present;  and  we  cannot  but  suppose  that  the  same  injurious  influence 
on  a  particular  habit  of  body  must  continue,  though  it  be  contaminated 
with  the  poison  of  syphilis.  The  best  proof  that  we  possess  of  the 
influence  of  mercuiy  over  constitutional  s^^philis — an  influence,  indeed, 
that  almost  approaches  to  the  nature  of  a  specific  action — is  in  the  case 
of  infantile  syphilis ;  here  mercuiy  will  not  only  cure  the  disease,  but 
will  eradicate  the  virus  from  the  sj’stem  in  a  wa}"  that  no  other  remedy 
can  accomplish. 

In  the  treatment  of  constitutional  sj-philis  with  mercury,  eveiy thing 
depends  on  the  proper  administration  of  the  remed}^  at  a  suitable  period 
of  the  case,  and  in  a  fitting  condition  of  the  constitution.  The  question 
as  to  the  propriet}"  of  the  administration  of  mercuiy  in  constitutional 
syphilis,  the  particular  preparation  to  be  used,  and  the  period  of  the  dis¬ 
ease  in  which  it  should  be  given,  must  be  determined  in  a  great  measure 
b}"  the  previous  treatment  of  the  primaiy  disease,  b}"  the  condition  of  the 
patient’s  general  health,  and  by  the  duration  of  the  secondary  sj’^mptoms. 
If  mercuiy  have  been  freel}'  given,  perhaps  in  repeated,  irregular,  and 
ill-conducted  courses,  for  the  cure  of  the  primary  affection ;  if  the  patient 
have  fallen  into  a  cachectic  state,  having  lost  flesh,  color,  appetite,  and 
spirits;  if  the  constitutional  affection  have  assumed  the  tertiary  form, 
and  have  deepl}"  implicated  the  bones,  mercuiy  should  not  be  given  at 
all;  or,  at  all  events,  not  without  proper  previous  preparation.  In  these 
circumstances  I  think  we  should  endeavor,  if  possible,  to  remove  the  con¬ 
stitutional  affection  without  mercuiy.  It  is  true  that  in  many  cases  we 
shall  not  succeed  in  doing  so;  but  at  least  we  improve  the  health,  check 
the  disease,  and  bring  the  patient  into  a  proper  condition  to  support  a 
mercurial  course,  should  it  be  thought  necessaiy  eventually  to  subject 
him  to  one.  It  is  in  these  conditions  of  the  s^^stem  that  the  nitro-mu- 
riatic  acid  and  sarsaparilla  are  of  much  service.  From  twenty  to  thirty 
minims  of  the  dilute  acid,  with  half  an  ounce  of  the  fluid  extract  of  sarsa¬ 
parilla  in  four  ounces  of  water,  may  be  administered  three  times  a  day. 
To  this  the  iodide  of  potassium^  in  five-grain  doses,  ma}"  often  be  advan- 
tageousl}"  added;  or  this  salt  ma^^be  given  alone  in  some  bitter  infusion, 
as  of  cascarilla,  quassia,  or  bark  ;  or,  if  the  patient  be  in  a  very  cachectic 
and  emaciated  state,  in  cod-liver  oil.  The  iodides  of  sodium  and  of 
ammonium  have  also  been  highly  spoken  of,  especially  by  some  Italian 
practitioners,  in  the  treatment  of  constitutional  S3"philis.  In  the  more 
advanced  cases  of  the  disease,  when  it  has  assumed  the  tertiary  form. 


TEEATMENT  OF  CONSTITUTIONAL  SYPHILIS. 


709 


and  the  constitution  is  much  broken  and  the  patient  ainemic,  the  prepara¬ 
tions  of  iron  may  be  given  with  much  advantage.  When  there  is  great 
emaciation,  I  have  found  the  combination  of  the  iodides  of  potassium 
and  of  iron  with  cod-liver  oil,  or  the  potassio-tartrate  of  iron  in  sarsa¬ 
parilla,  to  be  especially  beneficial.  But  useful  as  these  remedies,  espe¬ 
cially  iodide  of  potassium  and  the  dilute  mineral  acids,  unquestionably 
are,  more  especially  when  administered  in  the  compound  decoction  of 
sarsaparilla,  I  do  not  believe  that  they  exercise  any  specific  influence  on 
the  disease,  or  that  they  do  more  tlian  relieve  or  remove  local  manifesta¬ 
tions,  often  of  a  troublesome  and  disfiguring  character ;  failing  altogether 
to  cure  the  constitutional  afiection  and  to  eradicate  the  virus  from  the 
system,  for  which  purposes  mercury  will  at  last  be  required.  Their  great 
utilit}^  appears  to  consist  in  removing  cachex3",  and  in  restoring  the  vigor 
of  the  nutritive  and  reparative  actions,  which  are  in  abe^mnce;  and,  by 
improving  the  general  tone  of  the  s^^stem,  in  enabling  it  to  resist  more 
effectuall}'  the  advance  of  the  disease,  and  in  some  cases,  perhaps,  to 
allow  this  to  wear  itself  out.  That  great  advantage  results  from  main¬ 
taining  the  tone  of  the  system  in  S3q5hilis,  is  undoubted;  we  always  find 
that  the  intensity  of  the  ravages  of  the  S3q)hilitic  poison  is  in  direct  pro¬ 
portion  to  the  debility  and  want  of  resisting  power  in  the  constitution 
of  the  patient.  Besides  being  useful  in  this  wa3q  these  remedies  are  often 
of  service  in  removing  local  affections,  and  in  repairing  the  injury 
inflicted  upon  tissues  and  organs  by  the  low  and  specific  inflammation 
that  is  set  up  in  them.  In  this  respect,  indeed,  more  particularly  in  its 
advanced  or  tertiary  stages,  when  the  specific  nature  of  the  disease  is  to 
a  great  extent  worn  out,  and  little  remains  but  to  correct  the  cachexy 
and  malnutrition  that  have  been  left  as  the  result  of  long-continued  ill- 
health,  nothing  can  exceed  the  value  of  these  remedies  in  constitutional 
S3’^philis.  I  do  not,  however,  believe  that  the  disease  can  be  eradicated 
from  the  S3’'stem  by  these  means,  or  that  any  of  these  remedies,  even  the 
iodide  of  potassium,  can  take  the  place  of  mercuiy  in  the  treatment  of 
constitutional  S3’philis;  indeed,  I  cannot  call  to  mind  a  single  case  in 
which  this  form  of  the  affection  has  been  radicall3"  and  permanentl3’’  cured 
without  the  administration  of  mercuiy.  Those  cases  in  which  they  ex¬ 
ercise  most  beneficial  influence,  are  certainl3’'  instances  in  which  mercury 
has  been  injudiciousl3"  emplo3’'ed,  either  for  the  primary  or  the  secondary 
disease,  and  in  which  the  powers  of  the  constitution  have  in  this  way 
been  sapped.  In  these  circumstances,  a  course  of  the  iodide  of  jDotas- 
sium,  of  the  mineral  acids,  or  of  the  potassio-tartrate  of  iron  in  sarsapa¬ 
rilla,  should  alwa3"s  be  administered,  with  a  view  of  improving  the 
patient’s  general  healtli. 

Looking,  therefore,  upon  mercury  as  the  01113'  remedy  we  possess  that 
influences  directly  and  permanentl3'  the  venereal  poison,  I  think  that  it 
should  alwa3'sbe  administered  in  a  full  course  during  some  period  of  the 
treatment  of  constitutional  S3'philis.  The  time  at  which  it  should  be 
given  is  of  considerable  importance ;  thus,  it  is  usually  better  not  to  ad¬ 
minister  it  until  the  initiatoiy  p3'rexia  has  subsided  under  the  use  of  ordi¬ 
nary  antiphlogistic  treatment ;  nor  should  it  be  given  if  there  be  a  veiy 
marked  cachex3'.  After  this  has  been  removed,  however,  by  other  means, 
the  emplo3mient  of  mercuiy  may  be  proceeded  with. 

In  administering  this  remed3^  for  constitutional  syphilis,  we  must  not 
give  it  largel3',  so  as  to  affect  the  S3^stem  rapidl3q  but  as  a  mild  course 
for  some  weeks,  so  as  to  act  freel3'  upon  the  secretoiy  and  excretoiy 
organs,  and  thus  to  eliminate  the  poison  from  the  S3^stem.  The  most 
useful  preparations  are  the  bichloride,  in  doses  from  the  twelfth  to  the 


710 


VENEREAL  DISEASES. 


eighth  of  a  grain ;  or  the  green  iodide,  in  one-grain  doses  three  times  a 
day.  These  should  be  given  with  sarsaparilla,  which  keeps  up  the  power 
of  the  system  and  acts  freely  upon  the  kidne3"s  and  the  skin.  The  mer¬ 
cury  should  be  continued  for  at  least  from  three  to  six  w’eeks,  until  a 
decided  improvement  has  taken  place  in  the  constitutional  S3'mptoms.  I 
do  not  think  it  desirable  to  produce  salivation ;  all  the  good  effects  of 
mercury  can  be  obtained  far  short  of  this;  and,  indeed,  if  the  remed3^  be 
pushed  to  such  a  point  as  to  affect  the  mouth  or  gums,  it  will  commonly 
act  injuriousl3^,  by  depressing  the  powers  of  the  system  too  much.  I 
therefore  think  it  well  to  suspend  its  administration  whenever  an  impres¬ 
sion  has  been  made  upon  the  disease,  and  before  its  depressing  effect  has 
been  produced.  The  cautions  necessary  during  the  mercurial  course, 
when  administered  in  secondary  S3’philis,  are  precisely  similar  to  those 
that  we  have  described  as  necessary  during  the  primary  treatment  of  the 
disease. 

In  some  cases  of  constitutional  S3’philis,  affecting  the  skin  and  more 
superficial  structures,  mercury  ma3’^  conveniently  be  administered  by 
fumigation.  This  plan  of  treatment,  which  has  been  especially  recom¬ 
mended  by  Langston  Parker  and  H.  Lee,  consists  of  a  combination  of 
vapor-bathing  and  of  mercurial  fumigation  ;  and  these  gentlemen  speak 
in  the  highest  terms  of  the  value  of  this  remedy  in  syphilis,  as  shortening 
the  duration  of  ordinary  treatment,  and  permanently  curing  the  disease 
without  the  constitution  of  the  patient  being  in  any  wa3'  injured  b3^  its 
emplo3unent.  The  baths  may  also  be  associated  with  appropriate  inter¬ 
nal  treatment.  During  the  use  of  the  fumigations,  the  patient  should  be 
dieted,  and  be  put  on  a  full  course  of  sarsaparilla.  The  bath  may  be 
administered  every  second  day,  and  should  consist  of  about  a  drachm 
of  cinnabar  slowly  volatilized  1)3^  means  of  a  spirit-lamp,  at  the  same  time 
that  steam  is  disengaged  from  boiling  water.  In  this  way  I  have  often 
used  fumigations  at  the  Hospital  and  in  private  practice,  and  with  very 
great  success,  in  cases  of  syphilitic  cachexy  with  extensive  cutaneous 
disease  of  an  ecthymatous  or  rupial  character,  in  constitutions  in  which 
mercury  could  not  be  borne  in  any  more  active  form.  H.  Lee  prefers 
calomel  as  the  material  to  be  volatilized,  twenty  to  forty  grains  being- 
used  on  each  occasion. 

Subcutaneous  injection  of  mercury  has  been  employed  by  Lewin  and 
other  Surgeons  on  the  Continent,  and  by  Walker  of  Peterborough  in 
this  country.  The  salt  used  is  the  bichloride,  of  which  from  one-eighth 
to  one-fourth  of  a  grain  is  injected  in  solution  in  15  minims  of  water. 
Sigmund  of  Yienna,  who  has  tried  this  remedy  in  two  hundred  cases, 
insists  strongl3^  on  the  necessity  of  rest  after  the  injection,  so  as  to  ob¬ 
viate  the  occurrence  of  abscess  and  other  untoward  consequences  which 
have  been  observed  to  follow  it.  The  precise  value  of  the  subcutaneous 
injection  of  inercuiy  in  s3qohilis  has,  it  seems,  3"et  to  be  determined. 
Sigmund  believes  it  to  be  most  useful  in  the  constitutional  forms  of  the 

o 

disease  affecting  the  more  superficial  structures  and  the  osseous,  mus¬ 
cular,  and  fibrous  tissues. 

Whatever  plan  of  treatment  is  adopted,  it  should  be  carried  out  for 
a  sufficient  length  of  time ;  great  evil  often  resulting  by  intercepting  it 
too  suddenly,  and  being  contented  with  the  removal  of  the  local  mischief, 
whilst  the  disease  is  left  firmly  seated  in  the  constitution. 

Local  Secondary  Affections. — We  shall  next  proceed  to  describe 
the  character  and  treatment  of  the  different  local  forms  in  which  con¬ 
stitutional  S3q)hilis  manifests  itself.  These  ma3^  be  considered  as  the3" 
affect  different  tissues  and  organs,  and  require  separate  examination. 


SYPHILITIC  SKIN-DISEASES. 


711 


according  to  the  part  that  is  influenced  by  them.  We  shall  consider 
them  as  affecting  the  skin  ;  the  mucous  membranes  of  the  mouth,  nose, 
tongue,  palate,  and  larynx ;  the  eye,  bones,  testes,  and  muscles. 

1.  Syphilitic  Affections  of  the  Skin. — S3q3hilo-dermata  or  Syphilides 
present  various  modifications  of  appearance,  corresponding  very  closely 
to  the  different  groups  of  idiopathic  cutaneous  diseases  ;  thus  we  find 
exanthematous,  papular,  squamous,  vesicular,  pustular,  and  tubercular 
syphilitic  affections  of  the  skin,  with  various  ulcers  and  growths.  These 
differ  from  the  corresponding  simple  cutaneous  diseases,  in  their  redness 
being  more  dusky  or  coppeiy,  in  leaving  stains  of  a  brownish  or  pur¬ 
plish  hue,  in  their  outline  being  circular,  and  in  their  crusts  or  scabs 
being  dark,  blackish,  thick,  and  rugged-looking.  Besides  this,  syphilis 
modifies  materiall}''  the  general  character  of  the  cuticle,  causing  it  to 
assume  a  yellow  or  earthy  tint,  and  to  be  rough  or  powdery.  The  worst 
forms  of  these  affections  are  commonly  met  with  on  the  face  and  more 
exposed  parts  of  the  body. 

Syphilitic  skin-diseases  arrange  themselves  under  the  following  groups. 

The  Roseola  consists  of  blotches  of  a  reddish-brown  or  coppery  tint, 
which  becomes  more  distinct  as  the  redness  declines ;  they  vaiy  in  size 
from  small  circular  spots  to  large  and  diffused  patches.  These  are 
usually  first  observed  about  the  abdomen,  and  commonly  occur  early  in 
the  disease,  often  before  the  primaiy  sore  is  healed.  Sypliilitic  roseola 
usually  occurs  in  patients  who  have  had  chancrous  excoriation,  and  is 
very  frequently"  accompanied  by  an  eiy  thematous  condition  of  the  throat. 

The  Squamous  syphilide  occurs  in  small  patches  of  an  irregular  shape, 
of  a  red  and  somewhat  coppery  color,  which  are  commonly  covered  with 
thin  filmy-  scales.  In  many  instances  the  patches  are,  however,  quite 
smooth,  so  as  to  have  a  glazed  and  almost  shining  look.  They  are 
usually  situated  on  the  inside  of  the  arms  and  thigh,  often  on  the  scro¬ 
tum  and  penis,  even  occurring  on  the  glans.  They  also  frequently 
appear  on  the  palms  and  soles,  where  deep  fissures  and  cracks  are  met 
with.  About  the  lips,  the  squamous  sy-philide  gives  rise  to  deep  and 
troublesome  fissures.  It  is  often  associated  with  a  deep  and  excavated 
ulcer  of  the  tonsils,  with  iufiammation  of  the  iris,  and  not  uncommonly 
Tvdth  disease  of  the  periosteum  and  bones,  and  almost  invariably  follows 
the  indurated  chancre.  Associated  with  this  condition  are  large  brown 
patches  or  maculse,  which  occur  on  various  parts  of  the  body. 

The  Vesicular  syphilide  is  of  very  rare  occurrence.  In  one  case 
which  fell  under  my  observation,  it  appeared  in  the  form  of  clusters  of 
small  pointed  vesicles,  which,  on  drying,  left  gray  or  brownish  crusts 
and  coppery  marks. 

Syphilitic  Pustules.,  on  the  contraiy,  commonly'’  occur ;  beginning  as 
small  hard  papulae  of  a  coppery  hue,  slowly  softening  in  the  centre  into 
a  small  deeply'’  seated  pustule,  having  a  large  brown  or  coppery  areola, 
and  forming  speedily  large  circular  dark-brown  or  even  black  scabs  ; 
usually  fiat  and  irregularly-  crusted,  at  other  times  conical.  When  fiat, 
they  constitute  sy-philitic  ecthyma  ;  when  conical,  the  rupial  form  of  the 
disease.  After  their  separation,  troublesome  ulcers  of  a  circular  shape, 
and  with  a  rather  foul  surface,  are  commonly  left.  This  disease  first 
appears  upon  the  face,  but  speedily  shows  itself  on  various  parts  of  the 
body,  more  especially  on  the  extremities;  it  is  always  indicative  of  con¬ 
stitutional  cachexyq  and  often  appears  at  an  early'’  period  after  phage- 
dmnic  chancre ;  when  it  follows  other  forms  of  chancre,  this  is,  I  believe, 
owing  to  the  patient’s  sy-stem  having  in  the  mean  time  fallen  into  a  low 
and  broken  state. 


712 


VENEREAL  DISEASES. 


Syphilitic  Tuhei'cles  commonl3"  occur  a«  an  advanced  or  tertiary 
symptom  ;  they  appear  as  hard,  smooth,  flat  and  elevated  bodies  of  a 
reddish-brown  or  purplish  color,  seated  on  the  face,  the  tongue,  the 
limbs,  the  penis,  or  the  uterus.  They  may  be  resolved  by  proper  treat¬ 
ment,  but  have  a  great  tendency  to  ulcerate  and  to  destroy  the  parts  on 
which  they  are  situated,  giving  rise  to  large,  deep,  foul,  and  serpiginous 
sores. 

Syphilitic  Boils  of  an  indolent  character,  but  painful,  and  discharging 
a  thin  ichorous  pus,  with  a  core  of  shreddy  areolar  tissue,  and  leaving 
deep,  irregular,  and  foul  ulcers,  are  not  uncommonly  met  with. 

Syphilitic  Ulcers  may  result  from  pustules,  tubercles,  or  boils,  or  may 
commence  as  tertiaiy  sores  ;  they  frequently  occur  where  the  integuments 
are  thin,  or  where  they  are  moistened  by  the  natural  secretions  of  the 
part.  They  are  circular  with  elevated  edges,  and  tend  to  spread  in 
circles,  with  a  foul  grayish  surface ;  often  creeping  along  slowlj^,  and 
destroying  deeply  the  parts  they  affect ;  leaving  cicatrices  of  a  bluish 
or  brown  color,  thin  and  smooth,  which  are  apt  to  break  open  again  on 
the  application  of  any  slight  irritation. 

The  Hair  and  Nails  are  commonly  affected  in  advanced  constitutional 
syphilis;  baldness,  constituting  Syphilitic  Alopecia^  occurring  either 
generally  or  in  patches,  without  any  apparent  disease  of  the  skin.  Disease 
of  the  nails.  Syphilitic  Onychia^  occurs  in  two  forms,  either  as  a  foul 
ulceration  between  the  toes,  or  else  as  a  chronic  inflammation,  with  fetid 
discharge  in  the  matrix  of  the  nail ;  which  becomes  black,  more  or  less 
bent,  and  scales  off  with  the  formation  of  a  dirty  ulcer  under  its  detached 
edges. 

The  Treatment  of  Cutaneous  Syphilis  must  be  conducted  in  accordance 
with  the  general  principles  already  laid  down,  and  with  special  reference 
to  the  characters  of  the  concomitant  constitutional  condition,  or  of  the 
other  local  manifestations  accompanying  it.  In  the  early  stages,  when 
ushered  in  by  febrile  disturbance,  a  mild  antiphlogistic  treatment  is 
required  ;  when  the  p3U’exia  has  been  subdued  more  speciflc  measures 
must  be  had  recourse  to.  In  the  roseolar  forms,  the  treatment  of  the 
secondary  affection  should  be  guided  b}^  the  previous  management  of  the 
primary  sore.  If  mercury  have  been  given  for  this,  we  should  content 
ourselves  with  the  iodide  of  potassium  in  infusion  of  quassia,  or,  what  is 
better,  in  full  quantities  of  the  compound  decoction  of  sarsaparilla. 
Should  mercuiy  not  have  been  given  in  the  primaiy  sore,  recourse  must 
now  be  had  to  it.  In  the  squamous  sjq^hilide,  mercuiy,  I  think,  is  alwa^' s 
necessary ;  and  here  I  give  the  preference  to  the  iodide  over  the  other 
preparations.  In  the  pustular  forms,  syphilitic  rupia  and  ecthyma,  the 
constitution  being  commonly  shattered,  a  tonic  plan  of  treatment  is 
required  in  the  first  instance ;  after  which  the  bichloride  of  mercury  in 
tincture  of  bark  or  decoction  of  sarsaparilla  should  be  steadil}^  admin¬ 
istered.  In  these  cases  also  much  benefit  will  be  derived  from  the  mer¬ 
curial  fume-bath.  In  the  tubercular  s^q^hilide  much  the  same  treatment 
is  required  as  in  the  last  variety’;  in  these  cases,  however,  I  have  often 
found  Donovan’s  solution  of  the  greatest  possible  value,  the  disease 
rapidly  disappearing  under  its  use ;  the  same  plan  is  required  in  the 
management  of  syphilitic  boils.  In  the  treatment  of  secondary  syphilitic 
ulcers  we  shall  find  it  necessary  to  use  caustic  freel^q  with  the  view  of 
setting  up  a  new  and  more  health}''  action  in  the  part.  For  this  purpose 
nitric  acid,  or  the  acid  nitrate  of  mercury,  is  especially  serviceable  ;  on 
the  separation  of  the  slough  thus  produced,  the  sore  maybe  dressed  with 
red  precipitate  powder  or  ointment,  or  the  black  wash,  to  which,  if  there 


SYPHILITIC  AFFECTIONS  OF  MUCOUS  MEMBRANES.  713 


be  irritation,  opium  ma}’’  be  added — the  same  constitutional  treatment, 
especially  Donovan’s  solution,  being  employed.  In  syphilitic  alopecia^ 
the  internal  administration  of  bichloride  of  mercury  with  bark  or  iron, 
and  the  external  use  of  a  strong  stimulant,  such  as  the  nitrate  of  mer¬ 
cury  ointment  or  tincture  of  cantharides,  will  be  found  most  serviceable  ; 
and  in  syphilitic  onychia,  the  free  application  of  nitrate  of  silver,  fol- 
low’ed  by  the  black  wash,  and  bichloride  of  mercury  or  Donovan’s  solu¬ 
tion  internally,  is  the  proper  treatment. 

2.  Warts^  Excrescences^  and  Vegetations  are  commonly  met  with  in 
constitutional  syphilis,  especially  in  the  neighborhood  of  the  mucous 
canals,  being  usually  situated  in  the  neighborhood  of  the  anus,  perinseum, 
or  scrotum  ;  and  in  the  female,  upon  and  within  the  labia.  They  are  also 
very  frequently  met  with  about  the  tongue,  on  the  tonsils,  palate,  and 
lips.  When  occurring  in  the  neighborhood  of  the  organs  of  generation, 
they  are  usually  large,  flat,  soft,  slightly  elevated,  and  uniform  in  struc¬ 
ture  and  appearance,  moistened  with  a  good  deal  of  mucous  exudation, 
and  a  sort  of  perspirable  secretion  of  the  neighboring  skin.  When  seated 
in  the  mouth  or  throat,  they  are  usually  small,  and  not  so  distinctly  ele¬ 
vated  or  circumscribed,  but  look  rather  like  a  thickened  and  opaque  con¬ 
dition  of  the  mucous  membrane  in  these  situations.  These  secondary 
warts,  Gondylomata  or  Mucous  TwtercZes,  as  the}’’ are  often  termed,  differ 
essentially  from  the  primaiy  vegetations,  not  only  in  their  appearance 
and  general  uniform  character,  but  in  being  dependent  on  the  constitu¬ 
tional  nature  of  the  disease,  and  not  on  local  causes  solel}^,  such  as  the 
irritation  of  discharges  and  the  want  of  cleanliness.  They  are  also  cer¬ 
tainly  contagious;  and  I  have  known  many  instances  in  which  they  have 
been  distinctly  transmitted  in  this  w’a}’’;  and,  indeed,  it  is  by  and  through 
them  that  secondary  syphilis  is  transmitted  from  one  individual  to 
another,  without  the  evidence  of  an  antecedent  primary  sore.  Their 
Treatment  must  be  constitutional  as  well  as  local ;  the  constitutional 
means  should  consist  in  the  administration  of  the  bichloride  of  mercury 
with  sarsaparilla ;  and  the  best  local  treatment  with  which  I  am  ac¬ 
quainted  is  to  rub  them  freel}^  with  the  nitrate  of  silver,  dressing  the 
parts  in  the  interval  of  the  application  with  chlorinated  lotions.  Not 
being  pendulous  or  distinctly  protuberant,  they  do  not,  like  the  primaiy 
excrescences,  require  excision. 

3.  The  BIucous  Membranes  of  the  Moidh^  Nose,,  Pharynx,,  and  Larynx,, 
are  com monlj^ affected  with  secondary  syphilitic  eruptions;  these  assume 
the  form  of  mucous  tubercles,  or  of  the  exanthematous,  tubercular,  and 
ulcerative  syphilides.  The  exanthematous  affection,  corresponding  to  the 
roseolar  form  of  cutaneous  S3q3hilis,  and  arising  from  the  same  cause  and 
in  the  same  constitution,  principally  affects  the  palate  and  throat.  The 
tubercular  variety  corresponds  to  the  squamous  cutaneous  eruptions, 
and  is  chiefl^^  met  with  as  flat,  hard,  and  elevated  tubercles  in  the  inte¬ 
rior  of  the  mouth,  nose,  and  throat.  The  ulcerative  affection  of  the  mu¬ 
cous  membranes  assumes  a  variet}^  of  forms,  which  will  immediately  be 
described,  and  occurs  principally"  in  the  throat  and  nose.  The  exanthe¬ 
matous  affection  of  the  mucous  membrane  is  usually  an  early  sign  of  con¬ 
stitutional  syq^hilis,  frequently  showing  itself  a  few  w"eeks  after  the  pri¬ 
mary  occurrence  of  the  disease.  The  other  varieties  belong  to  the  more 
advanced  secondary"  or  tertiary"  periods. 

The  sy"philitic  affections  of  the  mucous  membranes  so  readily  extend 
to,  and  are  so  commonly  associated  with,  corresponding  disease  of  the 
deeper  structures,  that  we  shall  more  conveniently^  consider  their  different 
forms  according  as  they  affect  distinct  organs  or  parts  of  the  body". 


714 


VENEREAL  DISEASES. 


The  Lips  are  commonly  affected  in  persons  laboring  under  squamous 
S3q:)liilide,  with  fissures  or  cracks  usually  somewhat  indurated,  and  very 
painful  in  the  movement  of  these  parts.  In  the  Treatment^  the  applica¬ 
tion  of  a  pointed  piece  of  nitrate  of  silver  to  the  bottom  of  the  crack  will 
give  the  most  effectual  relief.  The  insides  of  the  cheeks  are  not  unfre- 
quently  affected  in  a  similar  manner,  or  become  the  seat  of  mucous 
tubercles,  which  must  be  treated  as  has  already  been  stated. 

The  Tongue  may  be  affected  with  syphilis  in  various  forms ;  when 
severely,  its  disease  usually  constitutes  one  of  the  tertiary  varieties  of 
the  affection.  In  maii}^  cases  the  mucous  membrane  becomes  thickened, 
but  preserves  a  peculiar  glossy,  semi-transparent,  almost  gelatinous  ap¬ 
pearance,  and,  being  irregularly  fissured,  gives  the  organ  a  thick  and 
misshapen  look.  In  other  instances,  the  epithelium  is  diy,  white,  and 
opaque  in  patches;  the  surface  of  the  tongue  looking  as  if  it  had  been 
d3'ed  white  here  and  there.  Occasionally^  ulcers  form  upon  its  surface  or 
sides;  these  are  usually^  irregular  in  shape,  with  a  foul  surface  and  a 
good  deal  of  surrounding  induration,  and,  unless  care  be  taken,  may 
readily  be  confounded  wdth  sciriiius  or  epithelial  cancer  of  the  organ. 
The  diagnosis  of  these  affections  we  shall  consider  when  speaking  of  dis¬ 
eases  of  the  tongue  generally^  Occasionally,  a  hard  elevated  circum¬ 
scribed  tumor  of  a  dark-red  or  purplish  color  slowly  forms  towards  the 
centre  of  this  organ  ;  it  increases  without  pain  and  in  a  gradual  manner, 
and  principally’^  occasions  inconvenience  by’’  its  bulk  and  the  impediment 
it  occasions  in  the  movements  of  the  tongue.  These  various  diseases 
usually  indicate  a  deeply  seated  constitutional  affection  of  the  tertiary 
tyq^e.  But  some  of  the  most  obstinate  cases  that  I  have  met  with  ap¬ 
peared  to  have  originated  from  direct  contact  of  the  tongue  with  the 
same  organ  in  another  person  the  subject  of  tertiary  lingual  syphilis, 
and  thus  from  direct  contamination.  The  Treatment  consists  in  the  ad¬ 
ministration  of  mercuiy,  either  in  the  form  of  iodide  or  of  bichloride. 
Donovan’s  solution  is  extremely’^  useful  in  many  of  the  more  inveterate 
of  these  cases.  The  ulcers  should  be  touched  from  time  to  time  with  the 
nitrate  of  silver. 

The  syphilitic  diseases  of  the  Throat  are  amongst  the  most  common 
manifestations  of  constitutional  syphilis,  and  frequently  occur  early. 
They’  present  several  distinct  forms,  corresponding  to  analogous  primary 
and  secondary  cutaneous  affections.  One  of  the  earliest  conditions  is  a 
deep-red  exanthematous  efflorescence  of  the  soft  palate  and  the  pillars 
of  the  fauces,  either  without  ulceration,  or  with  but  superficial  abrasion, 
but  with  much  cachexy  and  depression  of  power,  and  perhaps  with  con¬ 
siderable  pyrexia.  It  often  occurs  about  the  period  of  the  invasion  of 
the  roseolar  or  rupial  sy’philide,  and  requires  the  same  Treatment  as  is 
necessary  in  these  affections,  together  with  the  local  application  of  a 
strong  solution  of  the  nitrate  of  silver.  A  deep  excavated  ulcer,  with  a 
hard  base  and  foul  graydsh  surface,  of  circular  or  oval  form,  is  not  un- 
frequently  met  with  on  one  or  the  other  tonsil;  it  corresponds  to  that 
class  of  secondary  phenomena  that  follows  the  indurated  chancre,  and 
requires  mercuiy  in  some  form  for  its  cure ;  in  this  and  many  other 
cases  the  mineral  may  most  conveniently’  be  applied  to  the  throat  by 
means  of  fumigation.  A  sloughing  ulcer  is  occasionally  seen  on  the 
side  of  the  throat  or  palate,  with  much  swelling,  a  foul  gray  surface,  and 
rapid  destruction  of  parts,  giving  rise  very  commonly  to  perforation  of 
the  soft  palate,  and  thus,  by  partially  destroying  the  curtain  between 
the  mouth  and  the  nose,  occasioning  serious  inconvenience  to  the  patient 
during  deglutition  and  in  speech.  This  form  of  ulcer  is  connected  with 


SYPHILIS  OF  THE  LARYNX  AND  NOSE. 


715 


the  rupial  or  ecthymatous  S3'philicles,  and  requires  the  same  constitu¬ 
tional  Ti'eatment  as  these.  The  best  local  plan  is  free  sponging  with 
strong  nitric  acid,  and  gargling  with  solutions  of  the  chlorides.  More 
rarel^"^  a  form  of  the  serpiginous  ulceration  is  met  with,  producing  con¬ 
siderable  contraction  and  inconvenient  consolidation  of  tissues  after  its 
cure.  It  is,  I  think,  best  treated  by  the  local  application  of  nitric  acid, 
and  the  internal  administration  of  bichloride  of  mercuiy. 

The  mucous  membrane  of  the  Larynx  is  not  unfrequently  affected 
both  in  early  and  in  advanced  syphilis.  During  the  period  of  the  scaly 
eruptions  on  the  skin,  and  excoriation  of  the  fauces,  the  laiynx  is 
attacked  b}^  catarrhal  inflammation  and  by  the  formation  of  flat  slightly 
elevated  papules,  similar  to  those  seen  on  other  parts  of  the  bod}".  The 
symptoms  are  hoarseness  and  loss  of  voice,  and  occasional!}"  cough. 
They  usually  subside  without  leaving  any  permanent  injury.  In  these 
cases,  chronic  inflammation,  with  thickening  and  ulceration,  takes  place 
about  the  rima  glottidis,  with  the  general  and  local  symptoms  of  chronic 
laryngitis ;  such  as  huskiness  of  voice,  cough,  and  expectoration  of 
tenacious  or  offensive  mucus;  a  difficulty  in  deglutition,  and  a  tendency 
to  choking  on  swallowing  liquids,  with  tenderness  on  pressure  about  the 
throat,  also  come  on.  These  cases  are  usually  accompanied  by  much 
constitutional  cachexy,  and  not  unfrequently  eventually  terminate  fatally 
by  the  sudden  supervention  of  oedema  glottidis.  The  Constitutional 
Treatment  must  depend  upon  the  concomitant  symptoms  and  the  general 
state  of  the  patient ;  most  commonly  tonics  will  be  required.  The  Local 
Means  consist  in  the  free  application  of  the  solution  of  the  nitrate  of 
silver  to  the  rima  glottidis,  and  the  occasional  employment  of  counter¬ 
irritation.  In  syphilitic  ulceration  occurring  about  the  sides  or  base  of 
the  epiglottis,  care  must  be  taken  in  the  application  of  the  stronger 
escharotics,  such  as  nitric  acid  or  the  acid  nitrate  of  mercury ;  as  a  small 
quantity  of  these,  if  inhaled  into  the  larynx,  might  produce  serious 
difficulty  in  breathing,  or  even  fatal  asphyxia.  In  many  cases  it  may 
become  necessary  to  open  the  windpipe,  in  order  to  prevent  death  from 
asphyxia;  this  must  be  done  in  accordance  with  the  rules  that  will  be 
laid  down  when  treating  of  Chronic  Laryngitis. 

The  Nose  is  commonly  affected  in  constitutional  syphilis,  and  often 
destructively  so,  especially  in  individuals  much  exposed  to  changes  of 
temperature,  and  who  are  unable  to  pay  proper  attention  to  their  treat¬ 
ment.  The  mucous  membrane  becomes  chronically  thickened,  with 
discharge  of  blood  and  pus,  coryza,  and  habitual  snuffling.  In  other 
cases  ulceration  takes  place,  with  a  very  fetid  odor  of  the  breath,  and 
the  formation  of  thick  ecthymatous  crusts  on  the  septum,  or  between 
this  and  the  alfe.  This  ulceration  is  very  persistent  and  troublesome, 
and  requires  usually  a  mercurial  treatment  with  the  local  application  of 
strong  nitric  acid,  or  of  the  acid  nitrate  of  mercury,  to  arrest  its  pro¬ 
gress.  In  many  cases  ulceration  will  rapidly  proceed  to  destruction  and 
perforation  of  the  septum  or  necrosis  of  the  spongy  bones,  the  vomer, 
and  ethmoid ;  sometimes  excavating  the  whole  of  the  interior  of  the 
nose,  scooping  and  cleaning  it  out  into  one  vast  chasm.  When  this 
happens,  the  nasal  bones  also  are  usually  flattened,  broken  down,  and 
destroyed;  the  alse  and  colnmna  ulcerating  aw-ay,  and  producing  vast 
disfigurement.  Occasionally  the  disease  extends  to  the  bones  of  the 
base  of  the  skull,  and  in  this  way  may  occasion  impairment  of  vision, 
epilepsy,  or  death.  The  Treatment  of  these  nasal  affections  must  be 
conducted  in  accordance  with  general  principles.  In  many  cases 
mercurial  fumigation  is  extremely  useful;  in  others,  where  the  disease 


716 


YENEEEAL  DISEASES. 


is  ulcerative,  the  strong  acid  and  caustic  applications  already  mentioned  ? 
with  chlorinated  solutions  occasionally  sniffed  up,  will  do  much  to  stop 
its  progress.  As  necrosis  occurs,  the  dead  bone  must  be  removed. 

4.  Syphilitic  Iritis  usually  occurs  after  exposure  to  cold,  and  often  in 
people  who  are  otherwise  strong  and  health}*.  The  ordinary  symptoms 
of  iritis,  somewhat  modified,  characterize  the  affection.  The  patient 
complains  of  dimness  of  sight,  pain  in  the  eye,  and  often  of  very  severe 
circumorbital  or  hemicranial  pains.  On  examining  the  eye,  the  con¬ 
junctiva  will  be  found  to  be  slightly  injected,  and  a  zone  of  pink  vessels 
to  be  seated  on  the  sclerotic,  close  to  the  cornea;  the  aqueous  humor 
has  lost  its  transparency,  giving  a  muddy  look  to  the  eye,  and  the  color 
of  the  iris  is  altered.  The  pupil  is  irregular  in  shape,  usually  angular 
towards  the  nasal  side,  and  small  yellowish  or  brownish  nodules  of 
lymph  may  be  seen  to  be  deposited  on  the  surface  of  the  iris.  If  the 
case  be  left  to  itself,  or  be  improperly  treated,  it  will  advance  to  disor¬ 
ganization  or  to  permanent  opacity  of  the  eye.  The  retina  often  becomes 
affected,  and  incurable  blindness  results. 

The  Treatment  consists  in  local  depletion  by  means  of  cupping  and 
leeches  to  the  temples,  and  the  administration  of  calomel  and  opium 
internally,  at  the  same  time  that  a  drop  of  the  solution  of  atropine  is 
put  into  the  eye.  Most  commonly,  as  the  mouth  becomes  affected  by 
the  mercurial,  the  eye  Fill  clear,  the  lymph  becoming  absorbed,  and  the 
pupil  regaining  its  normal  shape  and  color.  In  some  cases,  however, 
a  chronic  inflammation  continues ;  here  the  best  effects  result  from  the 
administration  of  small  doses  of  bichloride  of  mercury,  with  repeated 
blistering  to  the  temples ;  and,  in  a  later  stage,  soda  and  bark  may  be 
advantageouslv  given. 

5.  Venereal  Periostitis  or  Nodes  may  occur  on  almost  any  of  the  bones ; 
but  the  disease  is  most  commonly  met  with  on  the  tibia,  the  clavicle,  or 
the  bones  of  the  forearm.  Some  joints  are  also  not  unfrequently  affected 
by  it ;  the  sterno-clavicular  articulation  and  the  knee-joint  are  especially 
often  its  seats.  Xodes  are  indolent,  elongated,  uniform,  and  hard  swell¬ 
ings,  sometimes  tender  on  pressure,  and  generally  but  little  painful 
during  the  day ;  but  at  night  the  aggravation  of  pain  is  peculiarly 
marked,  and  constitutes  perhaps  the  most  distressing  symptom.  They 
consist  of  a  thickening  of  the  periosteum,  with  some  plastic  effusion 
within  and  underneath  it,  and  occasional  thickening  of  the  subjacent 
bone;  they  may  continue  permanently  or  may  terminate  by  resolution ; 
they  never  suppurate,  unless  there  be  disease  of  the  subjacent  bone. 

The  Treatment  consists,  if  there  be  much  tenderness,  in  the  applica¬ 
tion  of  leeches ;  if  there  be  no  great  sensibility  on  pressure,  but  con¬ 
siderable  nocturnal  pain,  blisters  should  be  applied.  When  the  nodes 
are  in  a  chronic  state,  the  tincture  of  iodine  is  an  useful  application. 
Xodes  sometimes  become  soft  and  prominent,  and  feel  semi-fluctuating, 
especially  when  seated  on  the  cranium,  so  as  almost  to  tempt  the  Sur¬ 
geon  to  make  an  opening  into  them ;  this,  however,  should  never  be 
done,  as  the  swelling,  however  great,  will  subside  under  proper  treat¬ 
ment.  For  the  ultimate  removal  of  the  tumor,  and  the  relief  of  the  noc¬ 
turnal  pains,  we  possess  an  excellent  and  sure  remedy  in  the  iodide  of 
potassium,  carried  to  large  doses. 

Other  fibrous  membranes  besides  the  periosteum  may  become  diseased, 
and  masses  of  dense  lymph,  in  the  form  of  warty  tumors,  excrescences, 
or  nodules,  may  be  deposited  upon  them  as  the  consequence  of  the  syphi¬ 
litic  inflammation.  This  is  particularly  the  case  with  the  dura  mater  of 
the  brain  and  cord.  As  one  of  the  uiterior  effects  of  tertiary  syphilis, 


SYPHILIS  OF  THE  BONES. 


717 


structural  changes  of  this  kind  may  take  place  in  and  upon  tlie  dura 
mater  of  the  brain,  giving  rise  to  hemiplegia  and  epileptiform  seizures, 
and  eventually  coma  and  death,  partly  from  pressure,  partly  from  irrita¬ 
tion.  If  the  dura  mater  of  the  cord  be  affected  by  nodes,  more  or  less 
complete  paraplegia  will  result. 

6.  Diseases  of  the  Bones  are  amongst  the  more  remote  and  severe 
effects  of  constitutional  syphilis,  when  it  has  reached  the  tertiary  stage. 
By  some  Surgeons  they  are  said  to  be  the  result  of  the  administration 
of  mercuiy,  rather  than  of  the  syphilis  for  which  the  mineral  is  given. 
This  doctrine  I  believe  to  be  entirely  without  foundation.  That  tlie^”^  are 
met  with  in  syphilitic  cases  in  which  no  mercury  has  been  given,  there  can 
be  no  doubt.  I  have  had  under  my  care  patients  with  extensive  disease 
of  the  cranium  and  of  the  clavicle,  whose  syphilis  had  been  treated  from 
first  to  last  on  the  non-mercurial  plan.  One  patient  especiallj^  a  soldier, 
from  whom  I  removed  a  portion  of  the  cranium  and  of  the  clavicle  for 
necrosis  accompanying  constitutional  syphilis,  had  been  treated  in  a 
military  hospital  without  mercury.  I  have  never  seen  or  beard  of  mer¬ 
cury  producing  necrosis  in  any  bones,  except  those  of  the  jaws,  when 
given  for  other  diseases  than  syphilis.  No  doubt  diseases  of  the  bone 
are  especially  apt  to  occur  when  the  patient’s  constitution  has  been 
broken  down  by  any  means ;  and  an  improperly  conducted  mercurial 
course  may  have  this  result.  They  usually  occur  after  the  patient  has 
passed  through  the  whole  course  of  the  less  severe  syphilitic  affections, 
such  as  those  of  the  skin,  mucous  membrane,  and  throat.  The  affections 
of  the  bones,  however,  may  in  some  cases  declare  themselves  at  the  same 
time  with  the  affections  of  the  skin  and  mucous  membranes.  They  more 
commonly  occur  amongst  the  poorer  classes,  especially  those  who  are 
exposed  to  atmospheric  vicissitudes,  and  chiefly  in  strumous  consti¬ 
tutions. 

The  venereal  affections  are  principally  met  with  in  those  bones  that 
are  flat  and  compact,  as  the  cranial,  nasal,  and  maxillary  bones.  In 
these,  various  forms  of  disease  occur.  One  of  the  most  common  is  per¬ 
haps  Chronic  Ostitis,  wdth  hypertrophy  and  condensation  of  the  osseous 
tissues,  often  to  a  very  marked  extent.  This  affection  may  occur  in  the 
bones  of  the  skull,  but  is  also  met  with  in  some  of  the  long  bones,  as  the 
tibia  and  the  ulna;  it  is  characterized  by  very  severe  pain,  especially  of 
a  nocturnal  character,  accompanying  the  enlarged  and  thickened  state 
of  the  bone. 

Syphilitic  Necrosis  chiefly  occurs  in  the  bones  of  the  skull  and  jaws, 
the  alveolar  processes  of  which  may  exfoliate ;  the  palatine  process  of 
the  superior  maxillary  bone,  the  spongy  and  the  nasal  bones,  are  also 
commonly  destroyed  by  this  morbid  action ;  but  it  is  a  remarkable  fact 
that  the  palate-bones  are  not  nearly  so  often  affected  as  the  nasal  and 
spongy  bones.  In  consequence  of  this  destruction  of  bony  tissue,  the 
interior  of  the  nose  becomes  chronically  diseased,  and  the  organ  may  fall 
in,  or  a  communication  may  be  established  between  the  nose  and  the 
mouth  through  the  hard  palate. 

Syphilitic  Caries,  or  ulceration  of  bone,  presents  different  forms, 
which,  according  to  Stanley,  correspond  to  analogous  ulcers  and  erup¬ 
tions  of  the  skin.  Thus,  there  may  be  the  simple  ulcer  of  the  bone, 
showing  a  rough,  irregular,  porous,  and  depressed  surface ;  the  worm- 
eaten  caries,  consisting  of  small  pits  or  excavations,  studding  the  sur¬ 
face  ;  and  the  serpiginous  or  creeping  ulcer,  marked  by  imperfect 
attempts  at  repair,  and  the  deposition  of  new  bone  in  nodules  or  masses. 
The  cranial  bones  are  those  that  are  most  commonl}^  afiected  in  this  way; 


718 


VEXEEEAL  DISEASES. 


and  their  disease  ma}'  sometimes  prove  fatal  bj"  the  irritation  set  up  by 
it  in  the  brain  or  its  membranes.  The  bones  of  the  extremities,  how¬ 
ever,  are  not  nnfreqnently  similarlj^  affected. 

I  have  twice  seen  a  peculiar  dry  caries  of  the  cancellous  structure 
of  the  head  of  the  tibia  in  old  s^’philitic  cases.  In  both  cases,  which 
were  veiy  similar,  the  patients  had  been  affected  for  a  length  of  time 
with  nodes  of  the  tibia,  as  a  consequence  of  long  antecedent  syphilitic 
taint.  Chronic  abscess  eventuall}’  developed  itself  over  the  head  of  the 
tibia,  leading  to  carious  bones.  I  exposed  this  and  gouged  it  away.  It 
was  peculiarl}"  diy,  light,  and  almost  flocculent,  if  such  a  term  can  be 
applied  to  bone.  Both  patients  recovered  well  from  the  operation  ;  but 
one  of  them,  a  female,  died  two  years  afterwards  of  epilepsy,  consequent 
on  S3q)hilitic  tumors  of  the  dura  mater. 

The  Treatmeid  of  s^qffiilitic  disease  of  bone  varies  somewhat,  accord¬ 
ing  to  the  form  which  it  assumes,  and  the  previous  management  of  the 
patient.  In  ostitis^  the  principal  reliance  should  be  placed  upon  the  con¬ 
joined  influence  of  calomel  and  opium,  provided  the  patient  have  not 
previouslj’  been  fulh^  mercurialized.  If  he  have  been  so,  we  must  rely 
chiefl}'  upon  iodide  of  potassium.  In  the  more  advanced  and  intractable 
cases  that  liave  resisted  all  treatment,  I  have  found  the  greatest  advan¬ 
tage  result  from  cutting  down  upon  the  enlarged,  thickened,  and  tender 
bone,  and  b}^  means  of  a  He3"’s  saw  making  a  deep  cut  into  it  about  one 
and  a  half  or  two  inches  in  length,  parallel  to  its  axis,  and  down  to  the 
medullaiy  canal.  B3'  tliis  operation  the  tension  is  at  once  relieved,  and 
the  pain  effectuall3"  and  permanentl3’'  removed.  In  S3qffiilitic  necrosis^ 
the  constitutional  cachex3’ demands  the  principal  share  of  attention;  the 
necrosed  bone  should  be  separated  as  it  becomes  loose,  the  local  irrita¬ 
tion  depending  on  its  presence  then  subsiding.  When  the  bone  has 
fallen  into  a  caj'ious  state,  iodide  of  potassium  in  combination  with  iron, 
cod-liver  oil,  or  sarsaparilla,  with  the  mineral  acids,  will  improve  the 
tone  of  the  S3’stem,  and  sta3'  the  progress  of  the  disease.  The  ulcerated 
and  exposed  bone  requires  to  be  dressed  with  strong  stimulants;  the  red 
oxide  of  mercuiy,  in  ointment  or  powder,  is  perhaps  the  best ;  in  some 
cases,  touching  the  part  freel3'  with  the  acid  nitrate  of  mercuiy  will 
establish  a  more  health3’  action. 

I.  S3’philitic  disease  of  the  Testicle  is  one  of  the  more  advanced  con¬ 
ditions  of  the  constitutional  affection.  It  commonl3’’  occurs  as  the  result 
of  that  train  of  s3’^mptoms  that  consist  mainl3'  of  squamous  affections 
of  the  skin,  the  excavated  ulcer  of  the  throat,  iritis,  and  nodes,  but 
usuall3"  it  does  not  appear  until  these  different  manifestations  of  consti¬ 
tutional  S3’philis  have,  each  in  its  turn,  passed  awa3’ ;  the  patient,  indeed, 
appearing  to  have  recovered  from  all  disease,  and  being  otherwise  in 
good  health.  Commonl3"  the  exciting  cause  of  the  disease  ma3^  be  a 
blow,  a  squeeze,  the  occurrence  of  gonorrhoeal  epidid3’mitis,  or  some 
other  local  cause.  The  testis  then  graduall3^  enlarges,  until  it  attains 
the  size  of  a  turke3^’s  egg,  or  even  larger,  being  ovoid  in  shape,  heav3', 
and  smooth,  not  painful  except  b3"  its  weight,  which  causes  dragging  and 
nneas3’  sensations  in  the  cord  and  loins.  This  disease  is  veiy  commonly 
accompanied  by  a  small  lyulrocele,  constituting,  indeed,  a  h3"dro-sarco- 
cele.  Most  frequentl3-  01113'  one  testis  is  affected ;  veiy  rarel3’^  both  are 
diseased.  The  affection  continues  to  increase,  giving  rise  to  uneasiness 
from  its  size  and  weight,  but  is  not  followed  by  suppuration  or  other 
inconvenience. 

Hamilton  of  Dublin  has  described  another  form  of  S3qihilitic  sarco- 
cele,  under  the  term, “tubercular  S3'philitic  sarcocele.”  In  this  the  testis 


SYPHILITIC  DISEASE  'OF  THE  NERVOUS  CENTRES.  719 

is  enlarged  to  three  or  four  times  its  natural  bulk,  of  an  irregular  shape, 
presenting  an  uneven  and  knotty  mass;  it  is  neither  painful  nor  tender, 
but  inconvenient  from  its  weight,  causing  pains  in  the  loins  and  cord. 
Both  testes  are  usually  affected,  but  one  is  worse  than  the  other ;  and 
when  the  disorganization  is  great,  Hamilton  states  that  all  sexual  desire 
is  lost,  and  that  neither  erections  nor  emissions  take  place;  both,  however, 
returning  as  the  treatment  effects  the  restoration  of  the  organ  to  its 
normal  condition.  In  these  cases  suppuration  not  unfrequentl}^  takes 
place,  followed  by  the  discharge  of  thin  pus,  the  formation  of  fistulous 
openings,  and  occasionally  the  protrusion  of  a  fungus.  This  form  of 
saitjocele  occurs  in  persons  of  a  broken  and  cachectic  constitution,  who 
are  suffering  severely  from  the  more  advanced  and  inveterate  forms  of 
tertiary  s^'philis,  especially  of  the  bones  and  throat. 

In  the  simple  syphilitic  sarcocele,  the  enlargement  of  the  testis  is 
principally  due  to  the  deposit  of  semi-transparent  white  or  yellow  lymph, 
in  an  uniform  manner,  throughout  the  substance  of  the  organ  external 
to  the  tubuli.  In  the  tubercular  s^’^philitic  sarcocele,  Hamilton  states 
that  tubercles  of  a  yellow  color,  and  varying  in  size  from  a  split  pea  to 
a  chestnut,  or  even  larger,  are  found  in  the  substance  of  the  organ ; 
these,  softening,  give  rise  to  suppuration  in  and  around  them,  and  thus 
to  the  ultimate  disorganization  of  the  testis,  which  becomes  converted 
into  a  hard  irregular  fibro-cellular  mass,  in  which  cretaceous  matter  is 
occasionally  deposited. 

In  the  treatment  of  the  simple  form  of  sarcocele,  a  full  mercurial  course 
is  generally  necessary ;  the  bichloride,  in  doses  of  the  twelfth  or  eighth 
of  a  grain  three  times  a  day,  is  the  best  preparation.  This  should  be 
continued  for  at  least  six  or  eight  weeks,  or  until  hardness  disappears. 
All}'  hj’drocele  that  exists  should  be  tapped,  and  the  fluid  drawn  off  by 
means  of  a  small  trochar  and  cannula  before  the  treatment  is  commenced. 
After  the  mercury  has  been  discontinued,  the  remaining  swelling  of  the 
testis  may  be  removed  by  the  internal  administration  of  iodide  of 
potassium  in  five-grain  doses,  twice  or  thrice  daily,  with  frictions  with 
the  iodide  of  lead  ointment.  In  these  cases,  care  should  be  taken  not  to 
irritate  the  scrotum  with  very  stimulating  applications,  as  the  skin  is 
tender,  and  readilj^  becomes  excoriated ;  ordinary  strapping  is  of  very 
little  use,  but  in  some  cases  I  have  found  strapping  with  the  plaster  of 
ammoniacum  and  mercury,  diluted  with  equal  parts  of  belladonna 
plaster,  of  service.  If  suppuration  occur,  and  a  fungus  protrude,  the 
same  treatment  must  be  adopted  as  will  be  described  in  speaking  of  the 
strumous  testicle. 

8.  Syphilitic  Ovaritis  is  a  disease  that  I  believe  I  have  on  several 
occasions  met  with.  The  history  of  the  -cases  has  been  uniformly  as  fol¬ 
lows  :  a  long  antecedent  attack  of  sj^philis ;  various  constitutional  symp¬ 
toms  running  through  secondary  and  tertiary  stages;  inflammatory  con¬ 
gestion  of  one  ovary,  as  determined  by  abdominal  and  rectal  exploration  ; 
eventual  cure  by  means  of  leeching  and  the  bichloride  of  mercury  and 
bark ;  in  fact,  a  condition  of  things  closely  resembling  what  occurs  in 
syphilitic  sarcocele. 

9.  Syphilitic  disease  of  the  Nervous  Centres  is  occasional!}^  met  with 
in  the  more  chronic  forms  of  the  affection.  It  usually  manifests  itself  in 
the  form  of  paraplegia,  at  first  slight,  confined  to  some  loss  of  muscular 
power  in  the  lower  limbs  or  of  co-ordination  of  the  muscular  movements, 
so  that  the  gait  becomes  unsteady  and  insecure,  the  feet  being  turned 
out,  the  legs  carried  somewhat  apart,  and  the  limbs  propelled  in  a 
jerky  manner,  much  as  in  the  early  stages  of  locomotor  ataxy.  The 


720 


VENEREAL  DISEASES. 


sphincters  are  at  first  unaffected,  but  after  a  time  occasional  involuntary 
escape  of  flatus  may  occur,  or  there  may  be  some  trouble  about  the 
bladder — incontinence  or  retention,  or  the  two  conditions  combined. 
Sensation  in  the  lower  limbs  is  impaired,  often  irregularly  and  in 
patches.  As  the  disease  progresses  the  sight  becomes  affected  ;  double 
vision,  owing  to  strabismus,  being  commonlj’’  met  with.  Headache,  severe 
at  night,  is  complained  of,  and  eventually  one  arm  may  be  implicated, 
or  epileptiform  convulsions  come  on,  either  terminating  in  death  or  in 
destruction  more  or  less  complete  of  mental  power ;  thus  terminating  in 
a  most  miserable  ending  a  long  history  often  of  veiy  remote  and  early 
syphilitic  infection.  More  commonly  these  paral^^tic  states  are  conse¬ 
quent  on  an  indurated  chancre,  and  have  been  preceded  by  lengthened 
sufferings  from  nodes  and  SA’philitic  psoriasis,  possibly  by  iritis  as  well. 
As  has  already  been  stated,  these  afl^'ections  ma}’  be  owing,  in  some  cases 
at  least,  to  nodes  of  the  meninges  of  the  cord  and  brain.  The  treatment 
must  consist  in  iodide  of  potassium,  pushed  to  its  fullest  extent,  and,  if 
need  be,  the  iodide  of  mercury  as  well. 

10.  In  the  Limr^  towards  the  end  of  the  tertiary  stage,  gummy  tumors 
not  unfrequentl}’’  form ;  w’hile  at  the  same  time  a  general  interstitial 
hepatitis  may  occur,  causing  death  from  obstruction  to  the  hepatic 
circulation. 

11.  Besides  these  various  constitutional  manifestations  of  syphilis, 
tumors  of  the  Muscles  and  Tendons^  depending  on  this  disease,  have 
been  described  by  Bouisson.  These  consist  of  nodules  of  yellow  gummy 
matter,  like  .those  described  to  occur  in  the  testis ;  the}'  form  between 
the  muscular  fibres  from  the  connective  tissue.  The  muscles  are  also 
often  contracted  by  tough  adhesions  of  the  sheaths  and  insertions 
through  slow  inflammation  and  thickening  of  the  fibrous  tissue.  When 
affecting  the  tendons,  these  tumors  are  elongated,  and  resemble  nodes 
upon  them.  Their  presence  is  attended  with  some  pain  during  the  con¬ 
traction  of  the  muscle;  they  are  usually  somewhat  globular,  and  vary 
in  size  from  a  nut  to  a  pigeon’s  egg,  being  accompanied  by  nocturnal 
pains.  They  are  best  treated  by  the  iodide  of  potassium  in  large  doses. 

INFANTILE  SYPHILIS. 

Chancres  on  the  labia  of  the  mother  may  possibly  infect  the  child  at 
birth  with  either  of  the  two  forms  of  venereal  disease  that  have  been 
described,  just  as  they  may  inoculate  the  hand  of  the  accoucheur;  but 
syphilis  thus  contracted  by  the  infant  is  not  the  form  of  the  disease  that 
is  described  as  Infantile  Syphilis.  This  is  a  truly  hereditary  infection, 
transmitted  to  the  infant  at  the  time  of  its  conception,  or  communicated 
to  it  through  the  medium  of  the  mother  during  intra-uterine  life,  and 
existing  as  a  constitutional  affection  at  the  time  of  its  birth.  Though 
we  may  believe  that  syphilis  is  not  easily  eradicated  from  the  system 
into  which  it  has  once  been  received,  and  that  under  certain  conditions 
it  may  readily  be  transmitted  to  the  offspring ;  yet  I  think  that  we  are 
still  ignorant  of  the  amount  and  nature  of  the  constitutional  affection 
of  the  parents  that  are  necessary  for  the  development  of  syphilis  in  their 
children,  and  that  we  are  certainly  not  warranted  in  concluding  that  a 
parent  who  has  been,  or  even  who  is  actually  affected  by  constitutional 
syphilis,  must  necessarily  have  a  syphilitic,  or  even  a  feeble  or  strumous 
family ;  although  the  probability  undoubtedly  is  that  the  offspring  will 
be  syphilitic.  I  have  had  under  my  observation  a  gentleman  whom  I 
had  attended  for  secondary  syphilis,  and  who,  contrary  to  my  advice. 


COMMUNICATION  OF  SYPHILIS  TO  THE  FCETTJS.  721 


married  some  3^ears  ago ;  and,  though  he  had  since  then  suffered  from 
psoriasis  of  the  hands,  mucous  tubercles,  fissures  on  the  lips  and  tongue, 
and  venereal  sarcocele,  3^et  his  wife  has  borne  a  perfectly  healthy  famil}^, 
not  only  without  any  s}"philitic  taint,  but  without  any  apparent  consti¬ 
tutional  cachexy. 

When  the  ovum  is  infected  with  s\^philis,  several  morbid  states  may 
result,  according  to  the  intensity  of  the  infection.  It  may  be  so  blighted 
that  it  never  reaches  the  maturity  of  intra-uterine  life,  but  becomes  early 
absorbed ;  in  this  way  many  consecutive  miscarriages  ma}’’  happen  in 
consequence  of  one  or  both  of  the  parents  having  constitutional  syphi¬ 
lis  ;  but,  if  they  be  put  under  proper  treatment  by  a  mercurial  course, 
and  the  disease  be  thus  eradicated  from  the  s^^stem,  the  ovum  will  at  the 
next  pregnancy  probably  reach  its  full  development.  The  embr^’o  may 
go  its  full  time,  and  the  foetus  be  born  with  syphilitic  cachexy  and  local 
manifestations  of  the  disease  fully  developed  upon  it.  More  frequentl}^, 
however,  the  child,  although  cachectic  and  sickly  looking,  is  brought 
into  the  world  without  any  sjqDhilitic  appearances ;  but  in  the  course  of 
a  few  weeks,  usually  from  the  third  to  the  eighth,  these  declare  them¬ 
selves.  Constitutional  syphilis  of  a  congenital  nature  may  manifest 
itself  even  at  the  adult  age.  This,  though  rare,  has  fallen  under  my  ob¬ 
servation  in  a  ^mung  w^oman  of  seventeen  who  was  covered  with  marked 
s^'philitic  psoriasis,  with  which  she  had  been  affected  for  several  j^ears. 
The  mother  told  me  that,  shortly"  after  birth,  evidences  of  infantile 
syphilis  had  appeared ;  that  these  had  yielded  to  treatment,  but  that,  as 
the  period  of  puberty  approached*,  the  psoriasis,  which  was  truly  of  a 
S3q:)hilitic  nature,  had  shown  itself.  In  other  cases,  again,  it  is  not  im¬ 
possible  that  the  syphilitic  taint  may  manifest  itself  in  a  different  way 
from  that  which  has  just  been  alluded  to  ;  that  no  local  manifestation 
may  occur,  but  that  an  impaired  and  depraved  state  of  constitution  and 
of  nutritive  activity’’  may  be  inherited,  which,  in  after  life,  gives  rise  to 
some  of  the  various  forms  of  scrofula  or  of  other  constitutional  disease, 
dependent  upon  an  enfeebled  state  of  system,  or  a  diminution,  as  it  were, 
of  general  vitalit}". 

Mode  of  Communication. — The  mode  of  communication  of  syphilis 
to  the  ovum,  or  to  the  intra-uterine  foetus,  is  an  investigation  that  has 
much  occupied  the  attention  of  Surgeons,  and  is  of  considerable  practical 
interest.  It  has  been  considered  probable,  that  the  poison  may  be  com¬ 
municated  to  the  embryo  in  at  least  four  wa^^s :  viz.^  1,  the  father  may 
have  a  constitutional  taint  of  which  he  has  been  imperfectly^  cured,  and, 
without  communicating  any  syq^hilitic  disease  to  his  wife,  may  be  the 
parent  of  an  offspring  that  exhibits  indications  of  being  infected ;  or,  2, 
the  mother,  having  a  similar  constitutional  disease,  may  in  like  manner 
taint  her  own  offspring ;  or,  3,  the  diseased  child  may  be  born  of  parents, 
both  of  whom  are  constitutionally  infected  ;  or,  4,  the  mother  may’’  be¬ 
come  pregnant  with  a  healthy  embiyo,  but,  afterwards,  contracting 
syphilis,  may^  transmit  it  to  her  offspring. 

There  are  very  good  reasons  for  believing  that  the  disease  does  not 
pass  from  the  father  to  the  child  without  also  implicating  the  mother. 
In  the  first  place,  this  faculty  is  shared  by  no  other  contagious  disease. 
No  father  can  give  his  offspring  smallpox,  though  the  mother  frequently 
communicates  that  disease  to  her  foetus.  In  the  next  place,  it  is  well- 
known,  as  Colles  of  Dublin  long  ago  pointed  out,  that  a  congenitally 
syphilitic  child  never  locally  infects  its  mother,  though  it  will  transmit 
its  disease  readily  to  a  wet-nurse,  whose  breasts  it  sucks ;  this  apparent 
exemption  of  the  mother  being  due  to  the  fact  that  she  has  been  already 
VOL.  I _ 46 


722 


VENEREAL  DISEASES. 


infected.  Again,  the  symptoms  of  syphilis  are  often  exceedingly  mild 
in  women,  and  constantly  overlooked.  Hence,  in  the  present  state  of 
oiir  knowledge,  it  is  safer  to  conclude  that  the  father  infects  the  mother, 
and  that  she  transmits  her  disease  to  the  offspring. 

Ricord,  however,  states  that  a  mother,  pregnant  with  a  S3"philitic 
foetus,  the  offspring  of  a  father  laboring  under  constitutional  disease,  can 
be  infected  through  it  without  herself  having  had  primary  sj’philis ;  and 
Jonathan  Hutchinson  has  advanced  a  considerable  amount  of  evidence 
in  support  of  this  doctrine,  which,  nevertheless,  fails  to  carry  conviction 
to  my  mind  that  such  communication  ever  takes  place.  Then,  again, 
there  is  no  doubt  that  a  wet-nurse  laboring  under  constitutional  syphilis 
can  infect  the  child  that  she  suckles,  the  infant  being  contaminated 
through  the  medium  of  the  milk.  Ricord,  and  many  others  of  equal 
authorit}^,  admit  this.  My  own  opinion  is  that  s^qjhilis  is,  though 
rarel}",  so  transmitted ;  and,  indeed,  there  are  a  number  of  cases  on 
record  in  proof  of  this  {vide  Banking's  Abstract^  vol.  iv.).  The  converse 
of  this  is  also  a  matter  be3^ond  dispute:  a  S3qDhilitic  child  can  infect  a 
healthy  nurse.  This  point  is  one  of  very  great  importance,  inasmuch  as 
actions  for  damages  have  been  brought  b3"  women  who  have  stated  that 
they  have  become  diseased  from  the  child  that  they  have  nursed.  There 
are  cases  recorded  that  prove  it  incontestably;  and,  on  such  a  question 
as  this,  one  positive  fact  must  necessarily  outweigh  any  amount  of  nega¬ 
tive  evidence.  Kot  only  have  Hunter  and  Lawrence  related,  cases  in 
which  an  infected  child  communicated  the  disease  to  several  nurses  in 
succession ;  in  Hunter’s  cases  three  wet-nurses  were  successively  in¬ 
fected,  two  of  whom  gave  the  disease  again  to  their  own  children ; 
but  a  considerable  mass  of  evidence  upon  this  point  is  to  be  found  in 
Banking''^  Abstract  {loc.  cit.).  The  disease  is  especially  apt  to  be 
communicated  in  this  w^a3^,  if  the  nurse  have  any  crack  or  abrasion 
upon  her  nipple,  and  the  infant  sores  upon  the  mouth.  Colies,  how¬ 
ever,  who  had  great  experience  in  S3^philis,  states  that  the  disease  may 
be  communicated  to  the  nurse  from  an  infected  child,  by  mere  contact, 
without  excoriation. 

Symptoms. — The  s3"mptoms  of  infantile  syphilis  are  sufficiently 
well  marked:  consisting  principally  of  cachexy,  with  disease  of  the 
mucous  and  cutaneous  surfaces.  The  first  indication  is  usually  the 
atrophic  and  cachectic  appearance  of  the  child ;  this  not  infrequently 
shows  itself  at  birth,  and  when  it  does  so,  such  children  are  often  small, 
shrivelled,  wan,  and  wasted,  when  born;  the  face  especially  has  an  aged 
look,  the  features  being  pinched,  and  the  flesh  soft  and  flabby ;  the  com¬ 
plexion  generall3’  has  a  yellowish  or  earthy  tinge ;  and  these  characters 
continue  until  the  disease  is  eradicated  from  the  system  of  the  child. 
But  it  is  more  usual  for  the  disease  to  delay  its  appearance  until  a 
month  has  elapsed  after  birth.  Diday  and  De  Meric  have  collected  a 
large  number  of  cases,  in  most  of  which  the  disease  was  developed  in 
the  fifth  and  sixth  weeks.  Man3^  betrayed  their  disorder  in  the  first 
month ;  in  some  few  it  w^as  dela3^ed  until  the  child  had  attained  the  age 
of  three  months.  The  earlier  the  disease  shows  itself,  the  more  fatal 
are  its  effects.  Children  who  are  not  attacked  till  the3’'  are  two  or  three 
months  old,  usually  recover  their  health  in  a  sliort  time.  Nor,  when  the 
child  is  born  with  S3’philitic  eruptions,  is  it  always  atrophic  and  ill- 
nourished,  though  such  a  condition  is  the  ordinary  one. 

The  first  local  sign  that  declares  itself  is  usually  a  congested  condition 
of  the  mucous  membrane  of  the  ?iose,  giving  rise  to  the  secretion  of 
offensive  mucus,  and  causing  the  child  to  make  a  peculiar  snuffling 


SYMPTOMS  OF  INFANTILE  SYPHILIS. 


723 


noise  in  breathing,  as  if  it  had  a  chronic  catarrh;  this  snuffling  may 
exist  from  the  time  of  birth,  but  generally  comes  on  very  shortly  after¬ 
wards.  The  mucous  membrane  of  the  mouth  is  also  liable  to  attacks  of 
inflammation,  and  this  syphilitic  stomatitis  is  a  very  marked  character¬ 
istic  of  the  disease. 

The  disease  manifests  itself  upon  the  cutaneous  and  mucous  surfaces^ 
sometimes  before  or  at  birth,  in  other  cases  not  until  several  weeks  have 
elapsed.  The  most  common  period  for  the  occurrence  of  these  signs  is 
the  third  or  fourth  week.  The  cutaneous  eruption  usually  makes  its 
appearance  on  the  nates,  the  scrotum,  the  soles  of  the  feet,  and  around 
the  mouth;  hence,  in  examining  a  syphilitic  child,  these  parts  should 
alwaj’s  be  looked  at  first.  It  presents  itself  in  three  different  forms : 
most  frequently  as  flat  tubercles,  varying  in  size  from  a  split  pea  to  a 
fourpenn^^-piece,  smooth,  slightly  elevated,  and  of  a  coppery  or  reddish- 
brown  color.  These  tubercles  are  often  accompanied  by  cracks  and 
fissures  about  the  mouth  and  anus.  Though  commonly  called  squamous, 
the}"  are  not  in  reality  scaly,  but  are  alwa3's  smooth  and  flat.  Inter¬ 
mixed  with  these  are  brownish  maculae  or  spots,  differing  in  size,  and 
variously  figured. 

The  vesicular  bullous  eruption  is  not  so  common  as  those  just 
described,  yet  I  have  frequently  seen  it  in  S3q)hilitic  children.  It 
appears  in  the  form  of  vesicles,  about  the  size  of  a  sj^lit  pea,  with  a 
dusky  coppery  areola  and  base;  drying  into  brown  scales  or  scabs,  and 
commonly  conjoined  with  the  tubercular  affection.  These  bullae  are 
most  frequently  seen  on  the  soles  of  the  feet. 

When  we  consider  the  influence  exercised  by  the  syphilitic  poison 
upon  the  skin,  and  its  appendages  the  hair  and  nails,  we  should  a  priori 
have  expected  that  the  teeth,  as  a  portion  of  the  dermal  skeleton,  would 
participate  in  the  morbid  action  induced  by  it  on  the  allied  structures. 
The  fact  of  their  doing  so  does  not,  however,  appear  to  have  attracted 
the  notice  of  any  observer,  until  J.  Hutchinson  directed  the  attention  of 
the  profession  to  this  very  interesting  subject,  and  pointed  out  the 
destructive  and  special  influence  exercised  upon  the  teeth  by  secondary 
constitutional  syphilis.  This  injurious  influence  manifests  itself  both  in 
the  temporary  and  in  the  permanent  teeth ;  but  only  with  its  specific 
and  peculiar  characteristics  in  the  permanent  set.  It  must  not,  how¬ 
ever,  be  supposed  that  in  all  cases  of  infantile  syphilis  the  teeth  are 
affected ;  indeed,  in  many  instances  they  are  not,  and  it  has  been  par¬ 
ticularly  pointed  out  by  J.  Hutchinson  that  it  is  only  when  there  have 
been  attacks  of  S3q)hilitic  stomatitis,  that  we  are  to  expect  to  meet  with 
these  changes  in  the  teeth  from  their  normal  types. 

The  temporary  teeth  of  S3"philitic  infants  are  cut  earl}",  are  of  bad 
color,  and  liable  to  a  crumbling  deca}" 

(Fig.  245).  The  upper  central  incisors 
usually  suffer  earl}",  and  alwa3’'s  first; 
then  the  laterals  become  carious  and 
drop  out ;  and  lastl}",  in  some  cases, 
though  rarely,  the  canines  wear  awa}^  so 
as  to  present  a  tusk-like  appearance. 

In  consequence  of  the  earl}"  decay  of  the 
incisors,  children  are  often  edentulous, 
so  far  as  these  teeth  are  concerned,  from  an  early  age,  until  the  perma¬ 
nent  ones  are  cut. 

The  permanent  teeth  present  the  more  marked  characteristics  of  an 
inherited  syphilitic  taint;  and  in  these,  as  in  the  temporary,  the  disease 


Fig.  245. 


Syphilitic  Temporary  Teeth. 


724 


VENEKEAL  DISEASES. 


Fig.  246. 

m 


. . ‘""•"dlf''  . 

Syphilitic  Permanent  Teeth. 


declares  itself  chiefly  in  the  incisors  of  the  upper  jaw,  and  first  in  the 
central  ones.  These  will  be  observed  to  be  usually  of  a  bad  color,  short, 

peggy,  rounded  at  the  angles,  standing  apart  with 
interspaces,  or  converging,  and  marked  by  a  deep 
broad  notch.  They  are  soft  and  crumbling,  are 
slender,  and  readily  wear  down  (Fig.  246). 

Under  the  name  of  Chronic  Interstitial  Keratitis^ 
J.  Hutchinson  has  described  a  disease  which  he 
believes  to  be  uniformly  due  to  hereditary  syphilis. 
It  occurs  between  the  ages  of  5  and  18.  It  con¬ 
sists  at  first  of  a  hazy  condition  of  the  cornea, 
giving  it  the  appearance  of  ground  glass,  followed 
by  vascularization  without  any  tendency  to  ulcera¬ 
tion.  The  opacity  commences  in  the  centre,  and 
both  eyes  are  usually  affected.  The  vascularity  is  not  confined  to  the 
surface,  but  seems  to  pervade  the  whole  thickness  of  the  cornea.  One 
eye  is  usually  affected  before  the  other.  Under  a  carefully  conducted 
course  of  mercurials  and  iodides,  accompanied  by  tonics  and  good  diet, 
the  transparency  of  the  cornea  can  usually  be  restored. 

Treatment. — The  occurrence  of  syphilis  in  the  infant  may  be  pre¬ 
vented  by  putting  the  infected  mother  on  a  mercurial  course  so  soon  as 
her  pregnancy  is  ascertained  ;  this  indeed  may  be  necessary  in  order  to 
prevent  miscarriage,  but  should  be  done  cautiously,  and  by  inunction 
rather  than  by  mercury  administered  by  the  mouth.  Should  repeated 
miscarriages  have  occurred,  as  the  consequence  of  constitutional  syphilis, 
one  or  other,  or  both  the  parents,  if  at  fault,  should  be  put  upon  a  mer¬ 
curial  course  ;  and  thus  the  recurrence  of  this  accident  may  be  prevented. 

The  Curative  Treatment  as  regards  the  child  is  extremely  simple. 
It  should  be  brought  up  by  hand,  lest  it  infect  the  nurse  or  continue  to 
receive  fresh  accession  of  poison  from  the  diseased  milk  of  its  mother. 
It  must  then  be  put  under  the  influence  of  mercury,  which  in  these  cases 
acts  almost  as  a  specific  ;  and,  indeed,  the  ready  manner  in  which  all  dis¬ 
ease  may  be  eradicated  from  the  system  of  a  syphilitic  child  by  this 
mineral,  is  perhaps  one  of  the  strongest  proofs  that  can  be  adduced  of  the 
specific  character  of  its  action  on  the  venereal  poison.  The  mercury  may 
be  given  by  the  mouth  in  the  form  of  small  doses  of  hydrargyrum  cum 
creta ;  but,  as  it  often  purges  the  child  when  administered  in  this  way, 
Brodie  has  recommended  its  introduction  into  the  system  by  inunction, 
which  process  I  invariably  employ,  and  have  found  it  a  most  successful 
mode  of  treating  the  disease.  The  most  convenient  plan  is,  as  recom¬ 
mended  by  Sir  Benjamin,  to  spread  a  drachm  of  mercurial  ointment  on 
the  under  part  of  a  flannel  roller  stitched  round  the  thigh  just  above  the 
knee,  and  to  renew  this  every  day.  The  treatment  should  be  continued 
for  two  or  three  weeks,  until  all  rash  and  snuffling  have  disappeared, 
when,  the  mercury  having  been  discontinued,  the  cure  may  be  perfected 
by  the  administration  of  small  doses  of  iodide  of  potassium  in  milk  or 
cod-liver  oil.  Occasionally  the  cutaneous  manifestations  of  infantile 
syphilis  are  complicated  with,  and  obscured  by,  some  of  the  common  dis¬ 
eases  of  the  skin  incident  to  early  childhood;  more  particularly  with 
eczema  impetiginodes  of  the  head,  face,  and  body.  In  these  circum¬ 
stances,  the  diagnosis  may  not  be  easy,  though  the  history  of  the  case, 
the  concomitant  appearance  of  two  forms  of  the  disease,  and  the  exist¬ 
ence  of  snufliling  and  cachexy,  tend  to  establish  it.  The  eczema  also,  in 
these  circumstances,  is  browner  and  more  squamous  than  usual.  In 


WARTS  AND  CORNS. 


725 


cases  such  as  these,  the  best  plan  is  to  treat  the  syphilitic  affection  first 
with  the  mercurial  inunction,  and  then  to  put  the  child  under  a  mild 
course  of  Donovan’s  solution,  two  or  three  minims  for  a  dose,  keeping  it 
at  the  same  time  on  a  good  nonrishing  diet. 


DISEASES  OF  TISSUES. 


CHAPTER  XXXYII. 

SURGICAL  DISEASES  OF  THE  SKIN  AND  ITS  APPENDAGES. 

The  various  specific  cutaneous  afiections,  such  as  eczema,  scabies,  im¬ 
petigo,  acne,  lepra,  psoriasis,  etc.,  probabl}^  fall  within  the  province  of 
the  Surgeon,  and  are  commonl}'  treated  by  him  in  practice  ;  but,  as  the 
consideration  of  these  diseases  would  necessarily  lead  into  the  whole 
subject  of  Dermatology,  the  limits  of  this  work  would  not  allow  me  to 
discuss  so  extensive  and  special  a  branch  of  surgeiy ;  and  I  must  there¬ 
fore  content  myself  with  the  consideration  of  some  of  those  affections  of 
the  skin,  which,  as  requiring  manual  assistance,  ma}"  perhaps  be  more 
properly  looked  upon  as  within  the  scope  of  the  present  Treatise.  These 
diseases  may  be  considered  under  the  several  heads  of  Diseases  of  the 
Appendages  of  the  Skin,  as  of  the  cuticle  and  nails  ;  the  Non-Malignant 
Ulcers  of  the  Skin ;  and  the  Malignant  Ulcers  and  Tumors  of  this  tis¬ 
sue.  We  have  already,  in  Chapter  YI.,  considered  the  ordinary  non- 
malignant  ulcers  of  the  skin,  and  in  Chapter  XXXI Y.,  some  of  the  simple 
tumors  that  occur  in  connection  with  this  tissue ;  we  shall  here,  there¬ 
fore,  oiil}’’  consider  the  Diseases  of  the  Appendages  of  the  Skin^  and  the 
Malignant  Ulcers  and  Tumors. 

DISEASES  OF  THE  APPENDAGES  OF  THE  SKIN. 

Warts  consist  of  elongated  papillae,  with  strata  of  thickened  and 
hardened  cuticle,  usually  situated  about  the  hands  and  face,  and  chiefly 
affecting  3’oung  people ;  thej?-  appear  in  maii}^  cases  to  be  simple  over¬ 
growths  of  the  cutaneous  structures,  coming  and  going  without  aiw  evi¬ 
dent  cause.  In  other  cases  they  are  more  permanent,  becoming  hardened 
and  dark  in  color,  and  continuing  perhaps  through  life. 

The  Treatment  of  warts  is  usually"  sufficient!}’’  simple.  As  their 
vitality  is  low,  they  ma}”  be  readil}' destro^^ed  b}^  the  application  of  caus¬ 
tics  or  astringents ;  among  the  most  useful  of  these  I  have  found  the 
concentrated  acetic  acid  and  the  tincture  of  the  sesquichloride  of  iron. 
Brodie  recommends  the  solution  of  a  drachm  of  arsenious  acid  in  half  an 
ounce  of  nitric  acid.  In  some  cases  thej^  niay  be  ligatured  or  snipped 
off  with  advantage. 

Corns  usLiall}'  consist  of  small  thickened  masses  of  epidermis,  accu¬ 
mulated  on  those  points  on  which  undue  friction  or  pressure  has  been 


726 


SUEGICAL  DISEASES  OF  THE  SKIN, 


exercised,  in  order  to  guard  the  subjacent  cutis  from  injuiy.  These 
epidermic  masses  are  usuall}'  hard,  dry,  and  scaly;  at  other  times  they 
are  soft  and  spongy,  owing  to  their  being  situated  in  places  where  the 
secretions  of  the  skin  accumulate,  tlius  keeping  them  moist.  Under  old 
and  very  thickened  corns,  it  is  stated  bj’’  Brodie  that  a  small  bursa  is 
occasionally  found  ;  this  bursa  may  suppurate,  and  thus  become  very 
painful.  Corns  are  at  all  times  sufficiently  painful,  but  become  especially 
so  if  inflammation  or  suppuration  take  place  underneath  them ;  the 
accumulation  of  a  small  drop  of  pus  under  the  thickened  cuticle,  which 
prevents  its  escape,  giving  rise  to  very  intense  agony.  There  is  a  special 
form  of  warty  corn  that  I  have  seen  only  in  the  sole  of  the  foot,  and 
which  may  become  the  source  of  the  greatest  possible  pain  and  incon¬ 
venience  to  the  patient,  preventing  his  walking,  and  in  fact  completely 
crippling  him.  This  corn  is  usually  of  small  size  and  round  in  shape, 
the  neighboring  cuticle  being  always  greatlj''  thickened  and  hardened. 
It  is  extremely  sensitive  to  the  touch,  the  patient  shrinking  when  it  is 
pressed  upon,  as  if  an  exposed  nerve  had  been  injured.  On  slicing  it 
down  with  a  scalpel,  it  will  be  found  to  be  composed  of  soft,  tough,  and 
white  epidermis,  arranged  in  tufts  or  small  columns,  in  the  centre  of 
each  of  which  a  minute  black  dot  is  perceptible.  Each  tuft  appears  to 
be  an  elongated  and  thickened  papilla,  and  the  black  speck  is  a  small 
point  of  coagulated  blood  which  has  been  effused  into  it.  Around  the 
depression  in  which  each  of  these  corns  is  seated,  the  hardened  cuticle 
forms  a  kind  of  wall. 

The  Treatment  of  ordinary  corns  consists  in  shaving  or  rasping  them 
down  so  as  to  prevent  the  deep  layers  of  cuticle,  retained  by  the  indu¬ 
rated  superficial  ones,  from  giving  rise  to  pain  by  pressure  on  the  papillm 
of  the  cutis.  Belief  may  also  be  afforded  by  removing  all  pressure  from 
bearing  upon  the  corn,  by  attention  to  the  shape  of  the  shoe,  and  by 
wearing  a  piece  of  soft  leather  or  of  amadou,  having  a  hole  cut  in  the 
centre  into  which  the  corn  projects.  It  is  well  to  avoid  the  application 
of  caustics  to  ordinary  corns ;  injurious  consequences  being  often  pro¬ 
duced  by  these  agents,  especially  in  elderly  people,  in  whom  fatal  gan¬ 
grenous  inflammation,  as  I  have  seen  in  one  case,  may  be  excited  by 
their  action.  If  the  corn  suppurate,  it  must  be  poulticed  and  shaved 
down,  and  the  drop  of  pus  let  out  by  puncture  with  a  lancet.  In  the 
painful  papillated  corn  of  the  sole  of  the  foot,  I  have  found  the  applica¬ 
tion  of  potassa  fusa,  so  as  to  destroy  it  thoroughly,  to  be  the  best  and 
the  speediest  remedy,  and,  as  this  corn  always  occurs  in  young  people, 
no  danger  attends  its  use ;  or  a  poultice  followed  by  the  application  of  a 
blister  may  bring  it  away. 

Perforating  Ulcer  of  the  Foot  consists  in  a  sinus  that  traverses 
the  foot  between  the  metatarsal  bones.  It  is  unconnected  with  anj’- 
disease  of  the  osseous  or  articular  structures,  and  occurs  in  otherwise 
perfectly  healthy  persons.  The  mechanism  of  the  disease  appears  to  be 
as  follows.  A  hard  corn  forms  on  the  sole;  suppuration  takes  place 
under  this ;  the  pus  is  unable  to  escape  througli  the  indurated  cuticle, 
and  consequently  travels  upwards  and  finds  an  exit  on  the  dorsum  of 
the  foot,  through  an  ulcerated  opening  there.  On  passing  a  probe 
through  this  opening,  it  will  impinge  on  the  corn  in  the  sole,  in  which 
perhaps  there  may  be  found  a  small  perforation,  allowing  an  imperfect 
discharge  of  pus.  The  Treatment  consists  in  stimulating  the  interior 
of  the  sinus,  and  in  providing  an  aperture  in  the  sole  of  the  foot  for  the 
escape  of  the  pus.  •  This  is  done  by  passing  a  seton  of  two  silk  threads 
through  the  sinus. 


DISEASES  OF  THE  HAILS. 


727 


Diseases  of  the  Nails. — The  nails  may  become  diseased,  either  b}'’ 
undergoing  structural  changes,  by  having  their  matrix  inflamed,  or  by 
growing  into  the  soft  tissues  of  the  toes. 

In  some  broken  states  of  health,  and  especially  in  persons  suffering 
from  squamous  disease  of  the  skin,  the  nails  occasionally  become  blackish 
or  dark  brown  in  color,  are  rugged,  dry,  and  cracked,  scaling  off,  as  it 
were,  without  any  apparent  affection  of  the  matrix.  This  condition,  of 
which  I  have  seen  several  instances,  is  best  cured  by  a  course  of  altera¬ 
tives  and  sarsaparilla,  the  disease  yielding  as  the  general  health  becomes 
improved. 

Onychia  is  a  disease  of  the  nails  dependent  on  inflammation  of  the 
matrix ;  it  occurs  under  two  forms,  the  simple  and  the  specific. 

In  Simple  Onychia  there  are  redness,  heat,  and  swelling,  usually  on 
one  side  of  the  nail,  in  the  angle  of  the  tissue  in  which  it  is  implanted  ; 
there  is  discharge  of  pus,  and  the  nail  gradually  loosens,  becomes  dark  ' 
colored,  somewhat  shrivelled,  and  may  eventually  be  thrown  off,  a  new 
nail  making  its  appearance  below,  which  commonly  assumes  a  somewliat 
thickened  and  rugged  shape.  This  disease  usually  results  from  slight 
degrees  of  violence,  as  the  running  of  thorns  and  splinters  into  the 
fingers. 

The  Treatment  consists  in  subduing  inflammation  by  local  antiphlo- 
gistics,  poulticing,  etc.,  and  watching  the  growth  of  the  new  nail,  which 
may  be  sometimes  usefully  directed  by  the  application  of  a  layer  of  wax. 

Specific  Onychia  is  a  more  serious  affection,  and  is  often  dependent 
on  injuries  inflicted  on  the  finger  in  a  syphilitic  or  cachectic  condition 
of  the  system.  In  it  a  dusk3’’-red  or  livid  inflammation  takes  place  at 
the  sides  or  root  of  the  nail ;  ulceration  is  set  up,  accompanied  bv  the 
discharge  of  sanious  and  very  fetid  pus;  and  large  loose  granulations 
spring  up  at  its  root  and  sides,  so  that  the  end  of  the  toe  or  finger  that 
is  affected  (and  this  is  most  commonly  either  the  great  toe,  the  thumb, 
or  the  index  finger)  becomes  greatly  enlarged  and  bulbous  in  shape. 
The  nail  then  shrivels,  becomes  brown  or 
black,  and  peels  off  in  strips  (Fig.  247); 
after  its  separation,  thick  epidermic 
masses,  forming  abortive  attempts  at  the 
production  of  a  new  nail,  are  deposited  at 
the  base  and  sides.  In  the  Treatment., 
both  local  and  constitutional  means  are 
required.  The  first  and  most  essential 
point  is  to  remove  the  nail.,  either  in 
whole  or  part,  as  it  acts  as  a  foreign  bod}’’, 
and  prevents  the  healing  of  the  surface 
from  which  it  springs :  the  ulcer  should 

then  be  well  rubbed  with  the  nitrate  of  silver,  and  dressed  with  black 
wash.  Colles  recommends  fumigating  it  with  a  mercurial  candle,  made 
b}"  melting  a  drachm  of  cinnabar  and  two  ounces  of  white  wax  together. 
The  constitutional  treatment  consists  of  means  calculated  to  improve  the 
general  health ;  with  this  view  Sir  A.  Cooper  recommends  calomel  and 
opium.  I  have  generally  found  bichloride  of  mercuiy,  with  sarsaparilla 
or  bark,  the  most  useful  remedy. 

Ingrowing  of  the  Nail  is  an  extremely  painful  and  troublesome 
affection,  principall}’’  occurring  in  the  great  toe,  and  brought  about  by 
wearing  pointed  shoes,  by  which  the  sides  of  the  soft  part  of  the  toe  are 
pressed  upon,  and  made  to  overlap  the  edge  of  the  nail.  An  ulcer  here 
forms,  the  liability  to  which  is  greatl}’  increased  by  the  nail  being  cut 


Fig.  247. 


Syphilitic  Onychia. 


728 


SUKGICAL  DISEASES  OF  THE  SKIN. 


square,  so  that  the  flesh  presses  against  a  sharp  and  projecting  corner 
of  it ;  this  ulcer  secretes  a  fetid  sanious  discharge,  and  large  granulations 
are  thrown  up  by  it.  The  consequence  is  inability  to  walk  or  even 
stand  with  conoifort. 

Treatment. — Yarious  plans  have  been  devised  with  a  view  of  raising 
the  edge  of  the  nail,  partially  removing  it,  and  pressing  aside  the  soft 
structures.  I  have  never,  however,  seen  much  permanent  benefit  result 
from  any  of  these  means ;  and  the  only  method  that  is,  I  think,  really 
serviceable  to  the  patient,  is  the  removal  of  the  whole  nail.  As  this 
operation  is  an  excessively  painful  one,  the  patient  should  be  anesthe¬ 
tized  with  nitrous  oxide,  or  the  matrix  should  be  rendered  insensible  by 
the  ether-spray.  The  Surgeon  holds  the  diseased  toe  in  his  left  hand, 
and  then  running  one  blade  of  a  strong  sharp-pointed  pair  of  scissors 
under  the  nail  up  to  its  very  rooit,  he  cuts  through  its  wdiole  length,  and 

removing  the  scissors,  seizes  flrst  one  half  and  then  the 
other  with  a  pair  of  dissecting  forceps,  and  twists  them 
away  from  their  attachments.  The  raw  surface  left  is 
covered  with  water-dressing,  and  speedily  throws  out 
granulations  which  form  the  rudiments  of  a  new  nail. 
The  new  nail  usually  grows  straight  and  healthily.  In 
some  rare  cases,  however,  I  have  seen  a  faulty  direction 
assumed  by  it.  Avulsion  of  the  toe-nail  is  usually  un¬ 
attended  b\’  danger.  I  was,  however,  once  called  upon 
to  amputate  a  foot  for  gangrene,  which  had  followed  the 
operation  performed  on  an  elderly  person. 

Hypertrophy  of  Toe-nail. — Occasionally  from 
neglect  the  toe-nail  may  become  enormously  h3'per- 
trophied  and  twisted,  looking  more  like  a  horn  than  a 
nail,  as  in  the  accompanying  drawing  (Fig.  248),  taken 
from  a  patient  in  whom  the  nail  had  been  allowed  to 
grow  uncut  for  twenty  years,  producing  complete  lameness.  I  removed 
the  nail  whole  by  avulsion,  and  a  sound  and  useful  foot  resulted. 

MALIGNANT  TUMORS  AND  ULCERS  OF  THE  SKIN. 

Cheloid  and  Fibro- vascular  Tumors  of  the  skin  are  semi-malig¬ 
nant  growths  situated  on  the  trunk  and  extremities,  usually^  flat  and 
expanded,  oval,  round  or  irregular  in  shape,  slightly  elevated  above  the 
surface  of  the  skin,  and  commonly^  occurring  in  otherwise  healthy  indi¬ 
viduals.  They  may  remain  stationaiy  for  ymars,  but  not  uncommonly 
have  a  tendency  eventually''  to  ulcerate,  to  bleed,  and  to  assume  a  sort 
of  malignant  action;  at  other  times  they’’  extend  slowly’’,  without  ulcera¬ 
tion,  moving  forwards  as  it  were  upon  the  skin,  the  part  over  which 
they  have  passed  assuming  much  the  appearance  of  the  cicatrix  of  a 
burn,  being  red,  contracted,  drawn  in  towards  the  centre  and  wrinkled. 
Closely’’  allied  to  these  are  those  fibro-plastic  growths  that  have  a 
tendency  to  sprout  up  in  scars,  constituting  the  Warty  Tumors  of  Cica¬ 
trices.,  described  by'’  Cmsar  Hawkins.  This  morbid  condition  appears 
to  be  simply  an  abnormal  increase  in  the  activity’  of  the  development  of 
the  cicatricial  tissue,  which  springs  up  with  great  luxuriance.  They 
are  especially  apt  to  follow  the  irregular  cicatrization  of  burns,  more 
particularly^  in  children.  I  have,  however,  seen  them  in  the  adult,  occa¬ 
sioned  both  in  this  way"  and  by  the  irritation  of  a  blister.  The  warty 
cicatricial  tissue  chiefly"  develops  on  the  chest  and  neck,  and  is  com- 


Fig.  248. 


Hypertrophy  and 
Deformity  of  Toe¬ 
nail. 


LUPUS. 


729 


monly  attended  b}'  much  itching  and  tingling,  often  of  a  most  distressing 
character.  It  is  veiy  vascular,  bleeding  freeh'  when  incised. 

Treatment. — These  various  forms  of  tumour  should,  if  possible,  be 
extirpated  early  by  the  knife,  as  they  do  not  appear  to  be  amenable 
to  any  constitutional  or  local  treatment,  and  have  certainly  a  disposi¬ 
tion  to  malignant  degeneration.  As  there  is  a  great  tendenc}"  to  local 
recurrence  of  the  disease  after  removal,  it  should  be  wisel}-  excised;  but 
even  then  it  is  likely  enough  to  return,  requiring  perhaps  repeated 
operations  before  the  patient  can  be  freed  from  it. 

Lupus. — Under  the  term  lupus.,  various  simple  specific  semi-malig¬ 
nant  and  malignant  affections  of  the  skin,  of  very  different  kinds,  are 
commoul}"  included;  indeed,  the  distinctions  between  lupus  and  the 
different  forms  of  epithelial  cancer  have  not  as  yet  been  well  made  out ; 
and  the  term  “  lupus”  is  rather  loosely  applied  to  all  rapidly  destructive 
forms  of  chronic  ulceration,  more  especiall3"  when  affecting  the  skin  of 
the  face.  There  are  three  forms,  at  least,  in  which  the  diseases  included 
under  the  term  lupus  ma}^  make  their  appearance:  1,  as  a  superficial 
affection  of  the  skin,  not  attended  b}^  ulceration,  but  accompanied  b^" 
important  special  and  destructive  changes  in  its  tissue;  this  is  the  Lu¬ 
pus  Xon-exedens  of  some  writers;  2,  as  the  Lupus  Exedens,  a  disease 
of  a  rapid!}"  destructive  character,  not  only  eroding  superficially,  but 
destroying  the  tissues  deeply ;  3,  as  a  slowly  ulcerating  form  of  the  dis¬ 
ease,  giving  rise  to  the  different  varieties  of  Lupoid  or  Rodent  L^lcer. 
These  various  forms  of  lupus  are  most  commonly  seated  on  the  face  or 
neck,  but  are  occasionally  met  with  on  other  parts  of  the  body,  as  upon 
the  limbs  or  trunk. 

1.  Lupus  Non-exedens  appears  in  the  shape  of  a  red  patch  on  the 
skin,  covered  by  fine  branny  epidermic  desquamation;  it  may  remain 
stationary  for  years,  or  slowly  spread  over  a  great  extent  of  surface, 
producing  contraction  of  the  skin,  with  wrinkling  and  drawing  in  of 
the  features,  and  much  stiffness  in  their  movements.  The  integument 
affected  by  it  may  be  in  one  of  two  states;  it  may  either  continue  red, 
irritable  and  branny,  having  the  appearance  of  a  thin  cicatricial  tissue, 
and  in  this  way  the  greater  part  or  the  whole  of  the  face  may  be 
affected;  or  it  may  leave  a  firm,  white,  smooth,  and  depressed  cicatrix, 
exactly  resembling  that  produced  by  a  burn,  along  the  anterior  margin 
of  which  the  disease  slowdy  spreads,  in  the  form  of  an  elevated  ridge 
composed  of  soft  bluish-wliite  or  reddish  tubercles. 

2.  Lupus  Exedens.,  or  the  more  deeply  ulcerating  form  of  the  disease, 
may  begin  in  two  w-ays,  with  or  w'ithout  the  existence  of  a  tubercle  on 
the  skin.  It  is  most  commonly  seated  on  the  nose,  beginning  by  ulcera¬ 
tion  of  the  mucous  or  muco-cutaueous  surface,  without  any  precursory 
tubercle  as  in  the  lupoid  ulcer,  surrounded  by  redness  of  a  violet  or 
dusky  hue,  and  attended  by  much  inflammation,  swelling,  pain  and 
coryza.  The  ulcer  is  at  first  covered  by  a  thick  scab ;  as  this  separates, 
the  sore  extends,  and  often  rapidly  destroys  one  or  both  aim,  the  tip, 
and  columna ;  after  this,  the  destructive  action  usually  ceases  for  a 
time,  the  sore  crusting  over  with  grayisli,  hard,  and  adherent  scabs; 
but,  if  not,  it  may  go  on  eroding  one-half  the  face,  producing  a  frightful 
rugged-looking  cavity,  and  exposing  and  destroying  the  bones  and  large 
cavities  of  the  face.  I  believe,  howmver,  that  of  these  forms  of  disease, 
that  which  is  limited  to  the  nose,  and  that  which  extends  widely  over 
and  through  the  face,  essentially  differ  from  one  another.  The  first  is 
generally  of  a  Scrofulous  character,  in  fact  consisting  of  strumous 
ulceration  in  one  of  the  extreme  parts  of  the  body,  the  vitality  of  which 


730 


SUEGICAL  DISEASES  OF  THE  SKIN. 


is  below  its  normal  standard,  and  usually  occurring  in  young  persons, 
especially  in  Avomen  from  eighteen  to  twenty-five  years  of  age.  A 
second  A"ariet3Ms  of  Syphilitic  origin,  being  one  of  the  most -serious  forms 
of  remote  tertiary  syphilis ;  and  the  third  is  the  true  Lupoid  or  Rodent 
Ulcer. 

The  strumous  form  of  lupus  exedens,  that  which  destroys  merel}"  the 
extremity  of  the  nose,  is  commonly  rapid  in  its  progress,  the  part  appear¬ 
ing  to  melt  doAvn  under  the  disease,  so  that  in  the  course  of  a  few  weeks 
the  Avhole  of  the  organ  is  destroyed.  In  other  cases  it  is  very  slow, 
occupying  perhaps  many  years,  and  partaking  somewhat  of  the  red  and 
branii}^  form  of  lupus  non-exedens.  Occasionally  it  is  evidently  asso¬ 
ciated  with  and  dependent  upon  the  syphilitic  taint,  and  ought  then  to 
be  considered  rather  as  a  variety  of  local  syphilis  in  a  strumous  constitu¬ 
tion  than  as  a  distinct  affection. 

Microscopic  Structure. — It  is  not  often  that  we  have  an  opportunity  of 
examining  microscopically  the  structure  of  the  less  active  forms  of  lupus. 
Some  time  ago,  however,  I  removed  by  excision  a  patch  of  lupus  non- 
exedens,  which  had  existed  for  fourteen  years  under  the  chin  of  a  woman 
aged  thirty,  who  was  otherwise  in  good  health.  On  examination,  it  was 


found  to  be  composed  of  large 
cells  many  times  larger  than 
blood-discs,  having  clear  and 
very  distinct  cell-walls,  and 
well-marked  refracting  nuclei. 
There  were  some  cells  clear  and 
globular,  without  nuclei ;  others 
Avere  fusiform  and  elongated, 
with  nuclei,  evidently  under¬ 
going  fibro-plastic  transforma¬ 
tion  (Fig.  249).  Molecular 
movement  was  very  distinct 
in  one  of  these  globular  cells. 
The  mass  of  skin  appeared  to 
be  converted  into  granular 
matter,  intermixed  with  these 
cells. 


Fig.  249. 


Cells  from  Lupus  of  the  Neck.  Magnified  about  1200 
diameters. 


The  Diagnosis  of  scrofulous 
lupus  is  not  alwa^^s  easy,  the 


disease  being  speciall}^  apt  to  be  confounded  with  some  forms  of  impetigo, 
with  S3"philitic  tubercles  and  sores,  and  with  cancer.  From  impetigo  it 
may  be  distinguished  by  the  absence  of  pustules,  and  of  the  thick  gummy 
crusts  characteristic  of  this  affection,  as  Avell  as  by  the  less  extent  of 
surface  implicated,  and  the  deeper  and  more  eroding  form  of  the  lupoid 
ulceration.  From  syphilitic  disease  of  the  skin^  the  diagnosis  is  not 
alwa}^s  practicable,  inasmuch  as  true  lupus  may  occur  as  the  result  of 
constitutional  syphilis.  In  other  cases,  the  history  of  the  affection,  the 
limitation  of  the  disease,  and  the  absence  of  intervening  secondary 
manifestations,  make  it  easy  to  distinguish  one  from  the  other.  From 
ejnthelial  cancer.^  lupus  cannot  in  some  cases  be  distinguished  ;  the  two 
affections  indeed  being  closely  blended  together,  and  being  scarce!}’’ 
recognizable  as  distinct  diseases. 

The  Treatment  of  lupus  depends  in  a  great  measure  upon  the  variety 
of  the  disease  with  which  we  have  to  do,  and  the  constitutional  condition 
attending  it,  and  calls  for  the  employment  not  only  of  local  but  of  gene¬ 
ral  remedies. 


TKEATMENT  OF  LUPUS. 


731 


In  Lupus  Non-exedens  we  may,  if  the  disease  be  limited,  excise  the 
patch  and  heal  the  sore  that  results  granulation.  Xot  unfrequently, 
however,  the*  cicatrix  is  apt  to  undergo  fibro-vascular  degeneration.  If 
recourse  be  not  had  to  excision,  on  account  of  the  extent  and  super¬ 
ficial  character  of  the  disease,  it  is  useless  to  attempt  to  destroy  it  by 
caustics.  In  every  case  in  which  I  have  seen  these  means  tried,  the}"  have 
failed  in  effecting  a  cure.  In  some  instances,  however,  the  application  of 
a  strong  solution  of  the  nitrate  of  silver  to  the  morbid  surface  will  induce 
a  healthier  action;  though  in  the  majority  of  instances  local  applications 
of  a  soothing  kind  can  alone  be  borne.  Lotions  containing  glycerine  are 
especially  useful,  as  they  prevent  the  surface  from  becoming  dry  and 
harsh.  If  the  disease  be  situated  on  the  face,  care  should  be  taken  to 
avoid  exposure  to  cold  winds,  dust,  etc.  In  the  constitutional  treatment^ 
the  avoidance  of  stimulants  of  all  kinds,  the  use  of  a  bland  diet,  and  the 
employment  of  some  of  the  preparations  of  arsenic,  will  be  found  to  be 
the  most  likely  means  to  effect  a  cure.  Indeed,  arsenic  may  be  con¬ 
sidered  the  great  remedy  in  this  disease  ;  the  liquor  arsenicalis,  or  the 
iodide  in  combination  with  small  doses  of  biniodide  of  mercury,  will  be 
found  extremely  useful ;  Donovan’s  solutionis  also  most  beneficial  in 
many  instances. 

The  treatment  of  Lupus  Exedens  must  have  reference  to  the  consti¬ 
tutional  condition  in  which  it  occurs  ;  if  this  be  of  a  strumous  character, 
the  administration  of  cod-liver  oil  and  the  iodide  of  potassium,  with  a 
nourishing  diet,  will  be  most  serviceable  ;  in  a  syphilitic  constitution,  the 
remedies  that  are  applicable  to  the  cure  of  tertiary  syphilis,  such  as  the 
bichloride  of  mercuiy  and  Donovan’s  solution,  are  especially  useful.  In 
many  cases  also  in  which  there  can  be  no  suspicion  of  a  S3’philitic  taint, 
these  preparations  of  mercuiy,  as  well  as  the  iodides  of  the  same  metal, 
may  be  administered  empirically  with  great  advantage.  The  liquor 
arsenicalis,  or  the  combination  of  arsenic,  iodine,  and  mercury  that  ex¬ 
ists  in  Donovan’s  solution,  or  that  is  contained  in  a  pill  composed  of 
one-sixth  of  a  grain  of  iodide  of  arsenic  and  one-twelfth  of  a  grain  of  binio- 
dide  of  mercury,  as  recommended  b}'  A.  T.  Thomson,  has  appeared  to  me 
to  be  extremel}^  beneficial,  and  in  many  cases  certainly  exercises  a  marked 
influence  in  arresting  the  disease.  Whilst  the  patient  is  undergoing  a 
course  of  these  remedies,  much  attention  requires  to  be  paid  to  diet, 
clothing,  and  his  general  lygienic  conditions. 

In  the  local  treatment^  the  first  thing  that  requires  to  be  done  is  to 
subdue  inflammatory  action  and  irritation,  b}"  leeches,  emollient  lotions, 
and  opiate  or  henbane  poultices.  As  this  subsides,  the  progress  of  the 
disease  will  usuallj"  be  arrested  for  a  time  at  least ;  and  then,  hy  the  ap¬ 
plication  of  the  nitric  acid,  chloride  of  zinc,  or  the  acid  nitrate  of  mer¬ 
cuiy,  to  the  surface,  a  more  healtly  action  ma}'-  be  set  up,  and  the  sore 
be  made  to  cicatrize.  Great  mischief,  however,  may  result  if  the  caustics 
be  applied  too  earl^',  or  if  irritating  ointments  be  used,  as  the  destructive 
nature  of  the  disease  will  then  be  augmented.  The  inflainmatoiy  red¬ 
ness  and  branny'  desquamation,  resembling  lupus  non-exedens,  that  sur¬ 
round  the  ulcer,  may  usuall}"  most  readil^^  be  made  to  disappear  by  the 
repeated  applications  of  a  strong  solution  of  the  nitrate  of  silver,  which 
should  be  applied  every  second  day  b3''  means  of  a  camel-hair  brush. 
The  cicatrix  that  forms  in  this  disease  is  thin,  and  breaks  readil3’,  giving 
wa3'  on  exposure  to  cold,  or  on  the  occurrence  of  constitutional  derange¬ 
ment.  The  patient  should,  therefore,  for  some  length  of  time  after 
recoveiy,  be  careful  not  to  expose  himself  to  au3’'  such  influences.  In 
the  more  rapidl3’  spreading  and  worst  forms  of  lupus  exedens,  that  hor- 


732 


SURGICAL  DISEASES  OF  THE  SKIN. 


rible  disease  termed  by  the  older  Surgeons  “  Noli-me-tangere,”  nothing 
can  be  done  beyond  the  relief  that  is  afforded  b}^  the  administration  of 
opiates,  and  a  general  sedative  plan  of  treatment. 

3.  Lupoid  or  RodeM  Ulcer  is  one  of  those  remarkable  diseases  that 
stand  midway  between  simple  and  malignant  diseases;  being,  so  far  as 
constitutional  causes  or  secondary  complications  are  concerned,  appa¬ 
rently  of  a  simple  nature,  while,  in  regard  to  structural  condition  and 
local  effects,  it  is  of  a  malignant  character.  The  disease  is  especially 
characterized  by  its  slow  progress,  by  its  eroding  nature,  and  by  the  im¬ 
possibility  of  healing  it  b}^  all  ordinary  methods  of  treatment.  It  is  essen¬ 
tially  a  disease  of  advanced  age,  seldom  beginning  before  45  or  50.  Its 
duration  is  in  any  given  case  indefinite ;  seldom  less  than  five  or  six 
years,  occasionally  extending  to  twenty  or  thirty.  It  affects  individuals 
of  either  sex  indiscriminatel}’^;  and  usually  occurs  in  persons  who  are 
otherwise  perfectly  healthy.  The  health  also  is  not  influenced  materiall}’, 
if  at  all,  by  its  long  duration.  I  have  seen  persons,  who  have  been  vic¬ 
tims  to  it  for  more  than  twenty  years,  in  apparently  robust  health.  But 
it  is  eventually  and  inevitably  fatal,  unless  removed  by  operation. 

It  may  affect  any  part  of  the  head,  face,  or  extremities.  The  face  is 
its  seat  of  election.  It  spreads  simply  by  continuity  of  tissue,  never  by 
disseminated  local  or  by  secondary  deposits.  It  ma}^  invade  all  tissues  ; 
the  skin  primarily,  the  pinna  of  the  ear,  the  ahe  and  septum  of  the  nose, 
the  parotid  gland,  the  conjunctiva  and  the  eyeball.  It  is  especially  des¬ 
tructive  to  bone  when  once  it  attacks  it,  and  will  spread  deeply  into  the 
cancellous  structure,  as  of  the  head  of  the  tibia  or  thediploe  of  the  skull. 
It  erodes  and  eats  away  the  bone,  without  caries  or  necrosis.  It  may 
penetrate  the  dura  mater,  and  invade  the  brain.  Its  progress,  however, 
is  by  preference  superficial,  not  in  depth ;  hence  it  is  seldom  attended 
by  hemorrhage,  even  in  the  more  advanced  stages.  As  the  ulceration 
extends,  there  is  often  a  tendenc}^  to  imperfect  cicatrization  on  one 
margin,  whilst  the  disease  is  making  progress  at  the  other.  It  alwa^^s 
commences  in  the  skin,  usually  on  healthy  integument ;  but  occasionally 
it  primaril}^  affects  a  portion  of  the  skin  which  is  the  seat  of  some 
chronic  change  of  structure,  as  a  mole,  a  wart,  or  a  scar. 

Symptoms. — In  whatever  situation  it  begins,  its  first  appearance  is  in 
the  shape  of  a  tubercle  or  hard  pimple  of  a  brownish-red  color.  This 
is  most  commonl3^  seen  on  the  side  of  the  nose,  on  the  mouth,  or  on  the 
cheek.  This'  tubercle  ulcerates  slowly ;  and  then  the  disease  extends. 
Moore,  to  wdiom  we  are  indebted  for  a  most  lucid  account  of  this  terrible 
affection,  lays  especial  stress  on  its  commencement  in  a  hard  w'art,  and 
its  continued  extension  b}^  a  hard  margin.  This  ulcerated  tubercle  be¬ 
comes  covered  by  a  scab ;  but,  as  the  process  of  destructive  ulceration 
progresses,  the  sore  becomes  too  large  to  be  covered  by  a  scab,  and  an 
nicer  is  left.  This  ulcer,  which  constitutes  the  disease,  and  is  the  true 
“  Ai/pws,”  or  “  Noli-me-tangere'^  of  the  older  authors,  presents  the  fol¬ 
lowing  characters.  It  is  depressed  slightly  below  the  surface,  is  of  a 
pale  pink  color,  with  a  furrowed  rather  than  a  granulating  surface, 
resembling  b}’-  its  furrowed  smoothness  an  irregular  la3^er  of  pink  wax, 
and  is  usually  painless,  except  when  exposed  to  the  air.  It  slowly  ex¬ 
tends  by  a  margin  that  is  irregular  in  outline,  eroded,  and  pitted,  but,  as 
Moore  has  observed,  alwa3^s  has  a  hard  edge,  except  where  cicatrizing. 
The  ulceration,  sometimes  running  on  too  rapidly  for  the  margin,  invades 
and  destro3"s  it  in  parts,  cicatrizing  unequally  and  unhealthily^ ;  in  other 
cases  it  leaves  in  its  advance  a  track  of  bluish-reddish-white  thin  cicatrix, 
which  is  apt  to  be  again  invaded  and  destroy^ed  by  fresh  deposit  of  the 


EODENT  ULCEK. 


738 


lupoid  tubercle.  In  fact,  in  its  ulcerative  progress  and  eroding  action, 
it  destro^’s  its  own  indurated  margin,  eats  away  its  own  morbid  deposit 
more  rapidly  than  it  can  be  reformed,  and  so,  here  and  there  reaching 
healthy  tissues,  allows  an  opportunity  for  cicatrization  to  take  place  on 
one  side,  whilst  it  is  progressing  on  another.  The  cicatrices  are 
altogether  unstable,  and  are  liable  to  be  broken  down  by  these  renewed 
invasions  of  the  disease.  Whether  it  be  fast  or  slow,  the  advance  of  the 
disease  is  always  progressive ;  more  rapidly  in  the  skin,  more  slowly  in 
the  bone  and  less  vascular  tissues,  as  those  of  a  cartilaginous  and  fibroid 
character;  the  pinna  of  the  ear,  the  sclerotic,  and  the  septum  of  the  nose, 
for  instance.  When  it  attacks  bone,  it  will  perforate  this  structure,  and 
sink  deeply  into  its  softer  parts.  Moore  has  noticed  that  the  morbid 
growth  in  front  of  the  advancing  disease  is  always  most  clearly  marked 
in  cancellated  bone — in  the  diploe,  for  instance.  The  soft  parts  imme¬ 
diately  contiguous  to  the  disease  are  perfectty  healthy  and  uninfiltrated  ; 
and  there  is  never,  even  after  many  3xars  of  progress,  aity  sign  of  secon¬ 
dary"  affection  of  the  ly’mphatic  glands.  Unless  the  progress  of  this 
ulcer  be  arrested  by"  treatment,  it  is  never 
interrupted,  but  will  terminate  in  the 
death  of  the  patient.  This  fatal  termi¬ 
nation  may,  however,  be  long  delay^ed. 

The  accompanying  Fig.  250  is  from  a 
patient  of  mine  who  had  suffered  from 
the  disease  for  nearly  thirty  y^ears,  but 
who  was  to  all  appearance  in  perfect 
health,  although  the  skull  was  perforated, 
the  dura  mater  exposed,  and  the  pulsa¬ 
tions  of  the  brain  distinctly"  visible. 

Diagnosis. — The  diagnosis  has  to  be 
made  from  Epithelioma,  Syphilis,  and 
Lupus.  The  distinction  from  epitheli¬ 
oma  is  often  at  first  difficult ;  but  in  the 
larger  stages  the  absence  of  glandular 
affection,  the  small  amount  of  growth 
compared  to  the  ulceration,  and  the  pro¬ 
longed  course  of  the  case,  render  the 
diagnosis  easy".  From  tertiary  syphilis 
it  is  clearly  distinguished  by"«  the  duration  of  the  case.  In  syphilitic 
ulceration  “  the  rate  of  destruction  is  measured  by  weeks ;  in  rodent 
cancer,  by  y'ears,”  and  by"  the  absence  of  all  other  signs  of  constitutional 
sy"philis.  From  ordinary  liqnis  it  is  distinguished  by"  the  age  and  healthy" 
constitutional  state  of  the  patient,  by"  the  singleness  of  the  ulcer,  and 
the  absence  of  the  pink,  scaly",  or  oedematous  skin  frequently  found 
around  lupus.  Lupus  may  cicatrize  and  cease  at  any'  time ;  rodent  cancer 
never  does.  Lupus  possesses  contractility  ;  rodent  cancer  has  none. 
Lupus  rarely  causes  death ;  rodent  cancer  is  always  eventually  fatal. 

Pathology. — The  microscopic  characters  of  the  solid  infiltrating  sub¬ 
stance  have  been  examined  by"  Moore  and  Hulke,  both  of  whom  have 
found  some  parts  which  presented  appearances  identical  with  epithelioma. 
Moore  found  this  in  the  diploe  of  the  frontal  bone,  and  Hulke  in  a  part 
of  the  globe  of  the  ey-e  implicated  in  the  disease.  The  greater  part  of 
the  growth  presents  characters  differing  but  little  from  those  of  ordinary 
granulation  tissue.  Moore  was  of  opinion  that  the  growth  commenced 
in  all  cases  in  a  pimple  identical  in  structure  w’ith  epithelioma,  but  that 


Fig.  250. 


Rodent  Ulcer :  Perforation  of  Skull  and 
exposure  of  Dura  Mater. 


734 


SURGICAL  DISEASES  OF  THE  SKIN. 


this  character  was  lost  as  the  grow’th  extended,  but  could  be  readily 
assumed  again  in  “  certain  situations  or  in  convenient  textures.” 

We  have  seen,  from  the  foregoing  description  of  the  disease,  that 
rodent  cancer  is  a  solid  growth,  having  no  limitation  by  a  cyst,  infiltra¬ 
ting  and  superseding  the  natural  textures,  exhibiting  a  power  of  con¬ 
tinuous  increase,  infecting  the  adjoining  parts,  so  that  an  incision,  where 
they  appear  healthy,  is  yet  followed  by  a  return  of  the  disease,  and  ulti¬ 
mately  degenerating  and  disappearing,  destroying  with  itself  all  the 
tissues  which  it  had  penetrated.  On  these  grounds  Moore  considers 
himself  justified  in  classing  it  with  the  cancers,  in  spite  of  the  absence 
of  glandular  and  constitutional  infection. 

With  this  view’  I  cannot  concur.  Although  it  is  impossible  not  to 
admit  that  in  some  cases,  and  in  some  parts  of  most  cases,  rodent  ulcer 
is  in  its  histology  closel}’’  allied  to,  if  not  identical  with,  some  of  the  less 
active  forms  of  cancer,  yet  it  is  equally  certain  that  the  great  mass  of 
the  active  part  of  a  rodent  ulcer  presents  nothing  that  is  structurally 
cancerous,  and  that  clinicallj’  it  differs  from  all  and  every  variety  of  that 
disease  in  the  most  marked  manner.  We  have  abundant  proof  in  other 
diseases,  such  as  the  enchondromata,  for  instance,  that  they  ma3’'  differ 
from  cancer  histologicall}’,  but  resemble  it  clinicall}^  in  some  of  their 
varieties.  Ma}’  w’e  not  with  justice  see  the  converse  here :  viz.,  a  disease 
that  somewdiat  resembles  histologically,  but  that  differs  in  every  respect 
clinically  from,  a  cancerous  deposit  ?  Clinical  afifinitj’  is  surely  of  as 
much  account  as  histological  resemblance. 

Let  us  compare  the*two  affections  in  their  leading  characters. 

In  cancer  the  disease  often  commences  in  earl^’  or  at  most  middle  life  ; 
the  rodent  ulcer  alwa^’s  in  advanced  life  or  old  age.  In  cancer  there  is 
an  active  vegetative  outgrowffh  ;  in  rodent  ulcer,  destruction  and  absorp¬ 
tion  of  tissue.  Cancer  usually  commences  deeply — rarel}’’  in  the  skin, 
wdiich  is  involved  secondaril}^ ;  rodent  ulcer  alwa^^s  in  the  skin  primarily’, 
never  in  the  deeper  parts.  Epithelioma  ever  affects  primaril}'’  the  mucous 
or  muco-cutaneous  surfaces  ;  rodent  ulcer,  alwaj^s  the  true  skin.  Cancer 
is  rapid  in  its  local  progress  ;  rodent  ulcer  is  slow  beyond  any  other 
disease.  Cancer  is  often  primarily  multiple,  especiallj’’  wdien  superficial, 
developing  or  rapidlj^  extending  b^’  many  scattered  tubercles ;  rodent 
ulcer  is  alwa3^s  single,  arising  from  one  solitaiy  starting  point.  Cancer 
speedil}^  gives  rise  to  secondary  deposits  in  contiguous  structures  ;  rodent 
ulcer,  never.  Cancer  will  lead  to  secondaiy  visceral  deposits ;  rodent 
ulcer  never  leads  to  implication  of  internal  organs.  Cancer  produces 
constitutional  cachex}’,  blood-changes,  and  malnutrition ;  rodent  ulcer, 
even  when  most  chronic,  is  usuall}^  associated  with  perfect  health.  A 
cancerous  ulcer  shows  no  tendenc}’^  to  cicatrize;  a  rodent  ulcer  alwa^’s 
gives  evidences  of  imperfect  attempts  at  repair.  A  cancer,  when  removed 
by  operation,  almost  invariablj’  recurs ;  a  rodent  ulcer,  if  completely 
extirpated,  has  no  tendency  to  recurrence. 

Thus,  then,  in  all  essential  respects,  except  in  the  one  of  occasional 
similarity  in  structure,  so  far  as  the  hardened  edge  of  the  rodent  ulcer 
is  concerned,  the  tw’o  diseases  are  not  onl^’  so  dissimilar,  but  even  so 
clinically  antagonistic,  that  it  does  not  appear  to  be  justifiable  to  group 
them  together.  It  ma3',  in  fact,  be  said,  that  rodent  ulcer  is  allied  to, 
but  not  analogous  to,  the  cancers ;  that  it  is  more  local  and  less  consti¬ 
tutional,  even  secondarily,  than  epithelioma ;  that,  although  allied  to 
and  in  parts  presenting  some  of  the. characteristics  of  this  disease,  yet  it 
approaches  more  nearl3^  by  far  the  ordinaiy  structure  of  granulation- 
tissue ;  that  in  point  of  malignanc3’,  indeed,  it  stands  in  the  same  rela- 


TREATMENT  OF  RODENT  ULCER. 


735 


tion  to  epithelioma  that  this  latter  form  of  cancer  does  to  the  more 
active  variety  of  scirrhus ;  that  there  is  just  enough  of  malignancy  in  it 
to  prevent  the  attempts  of  cicatrization  from  becoming  effective,  but  not 
enough  to  occasion  rapid  progress  in  local  ulceration,  or  to  give  rise  to 
constitutional  infection.  From  scirrhus  to  epithelioma,  from  epithe¬ 
lioma  to  rodent  ulcer,  we  thus  find,  with  certain  intermediate  links  of 
structural  affinity,  a  progressive  decadence  in  the  force  of  malignant 
action. 

Treatment. — In  the  treatment,  constitutional  remedies  are  of  no  use, 
and  local  means  alone  are  to  be  relied  on.  They  consist:  1,  in  the  ap¬ 
plication  of  caustics ;  2,  in  excision  of  the  part ;  3,  in  a  combination  of 
these  two  methods. 

1.  The  ulcer  may  best  be  destro3^ed  by  the  application  of  the  chloride 
of  zinc  paste  to  the  whole  of  its  surface.  The  best  mode  of  applying 
this  is  to  keep  the  chloride  prepared  for  use  b}'  being  mixed  with  two 
or  three  parts  of  flour.  When  wanted,  a  sufficient  quantit}’'  of  this 
powder  should  be  made  into  a  stiff  paste,  by  the  addition  of  a  little 
water,  and  then  spread  over  the  surface  to  be  attacked  b}^  it,  in  a  la}'er 
of  about  the  thickness  of  a  wafer  ;  this  should  be  left  on  for  two  or  three 
hours,  and  then  removed,  the  sore  being  covered  with  a  piece  of  water¬ 
dressing  until  the  grayish  slough  that  has  been  produced  has  separated, 
when  the  caustic  may  be  reapplied  as  often  as  necessaiy.  Besides  the 
chloride  of  zinc,  various  other  caustics  may  be  had  recourse  to,  each  of 
which  possesses  some  peculiar  advantages.  The  nitric  acid  is  useful,  if 
the  action  to  be  produced  be  not  required  to  bd  veiy  deep  ;  for,  as  it 
hardens  and  coagulates  the  tissues  to  which  it  is  applied,  it  does  not 
consequently  extend  so  far  as  the  chloride.  The  acid  nitrate  of  mercury 
presents  the  same  advantages  as  the  nitric  acid  and  other  fluid  caustics 
— that  it  can  be  applied  into  the  fissures  and  hollows  of  the  part  into 
which  the  more  solid  caustics  do  not  penetrate,  and  is  certainly  useful 
in  inducing  a  health}^  action  in  the  part,  especiall^^  if  there  be  a  syphilitic 
taint.  The  potassa  fusa  and  Vienna  paste  are  useful,  so  far  as  their 
destructive  properties  are  concerned,  but  are  somewhat  uncontrollable, 
and  apt  to  spread.  The  most  convenient  mode  of  applying  them  is  to 
cut  in  a  piece  of  plaster  a  hole  of  the  exact  size  and  shape  of  the  ulcer, 
to  apply  this  around  its  borders,  then  to  cover  the  sore  with  a  la^^er  of 
potassa  cum  calce,  one  line  in  thickness,  and  over  this  to  la^^  on  another 
piece  of  plaster.  In  this  way  a  considerable  amount  of  caustic  action 
ma^'  be  induced,  which  wdll  be  limited  to  the  exact  surface  to  which  it 
has  been  applied.  Of  all  these  escharotics,  the  preference  is  to  be  given 
to  the  chloride  of  zinc;  its  action  is  more  continuous  and  more  control¬ 
lable,  and  it  appears  to  give  a  health^"  stimulus  to  the  subjacent  struc¬ 
tures. 

2.  Excision  of  the  whole  of  the  ulcer  may  sometimes  be  veiy  advan¬ 
tageously  practised,  especially  when  it  is  situated  on  the  cheek,  e3^elid, 
e3^e,  or  forehead ;  and  the  gap  left  ma3^  be  filled  in  by  some  of  those 
plastic  processes  that  will  be  described  when  we  come  to  speak  of  the 
Plastic  Surgeiy  of  the  Face. 

3.  When  the  ulcer  has  attained  a  large  size,  when  it  is  complicated  in 
its  outline,  and  irregular  in  its  depth,  the  question  arises  whether  surgeiy 
offers  aiy  resource,  or  whether  the  patient  should  be  left  slowl3^  and 
miserably  to  die. 

In  these  extreme  cases  even,  something  may  be  done  to  prolong  life 
and  to  relieve  suffering,  even  if  no  cure  be  ultimately  to  be  expected. 
Moore  proved  that,  unless  the  brain  be  implicated,  or  some  large  vessel 


736 


SURGICAL  DISEASES  OF  THE  SKIN. 


involved,  something  can  usually  be  done  at  least  to  arrest  the  rapidity 
of  the  growth.  The  method  which  he  adopted  was  a  combined  use  of 
the  knife  and  of  chloride  of  zinc.  these  means  he  removed  in  some 
cases  the  whole  of  the  affected  parts,  leaving  a  huge  chasm  in  the  face, 
and  even  in  one  case  exposing  the  dura  mater  for  a  considerable  extent 
over  the  roof  of  the  orbit.  The  operations  were  done  on  no  regular  plan, 
the  incision  being  directed  solely  b}^  the  shape  of  the  growth,  and  no 
attempt  being  made  to  repair  the  deformity  left.  The  results  of  these 
operations  were,  on  the  whole,  unfavorable.  Out  of  six  cases  three 
recovered,  and  the  three  others  received  decided  benefit,  but  were  not 
permanently  cured.  In  all  the  cases  in  which  the  chloride  of  zinc  came 
into  actual  contact  with  the  dura  mater,  epileptiform  fits  occurred,  but 
only  of  a  temporary  character. 

When  the  disease  is  situated  in  an  extremity,  and  the  cancellous  end 
of  a  bone  especially  is  involved,  as  when  it  dips  into  and  erodes  the 
head  of  the  tibia  or  the  lower  end  of  the  radius,  amputation  would  be 
the  proper  and  only  advantageous  procedure. 

When  the  disease  is  so  extensive,  or  so  situated,  that  absolutely  noth¬ 
ing  in  an  operative  wa}-  can  be  done,  the  Surgeon  must  content  himself 
b}"  covering  up  the  raw  surface  with  lint  soaked  in  glycerine  and  water, 
and  protected  by  oiled  silk. 

Cancer  of  the  Skin. — Cancer  may  occur  in  the  skin  as  a  true 
scirrhous  or  encephaloid  deposit ;  most  commonly,  however,  those  affec¬ 
tions  of  the  skin  termed  cancerous  consist  of  the  epithelial  form  of  the 
disease,  and  are  usuall}’’  seated  about  the  lips,  face,  and  scrotum,  or  at 
the  orifices  of  the  mucous  canals ;  these  we  have  already  considered 
generall}^,  and  shall  have  to  revert  to  them  more  fully  when  treating  of 
the  special  affections  of  these  parts. 

True  cancer  of  the  skin  may  occur  in  three  forms:  1,  as  the  Indurated 
Wart  of  a  scirrhous  character,  specially  described  by  Scarpa  ;  2,  as 
Scirrhous  or  Encephaloid  Infiltration  and  Fungus ;  or,  3,  as  Ulcers 
wliich,  primarity  originating  from  some  local  irritation  of  a  simple  kind, 
may,  by  the  persistence  of  this,  assume  a  truly  cancerous  character ;  thus 
I  have  seen  the  scrotum  and  the  neighborhood  of  the  apertures  of  fis- 
tulae  in  perinseo,  in  a  case  of  old-standing  disease,  become  converted 
into  a  truly  scirrhous  mass. 

Cancer  of  the  skin  is  apt  to  assume  a  melanotic  character,  owing  to 
the  large  development  in  it  of  black  pigmentary  matter.  Closety  allied 
to  it  in  appearance,  if  not  in  histological  structure,  is  the  Melanotic 
Sarcoma^  wUich  may  be  developed  in  connection  with  the  integumentary 
structures.  I  have  lately  met  with  such  a  tumor,  about  as  large  as  a 
walnut,  on  the  outside  of  the  foot  of  a  lady  in  her  seventeenth  year.  It 
was  successfully  removed  by  chloride  of  zinc  paste,  as  described  (p.  735). 
Some  time  after  its  removal,  black  patches  appeared  in  the  epidermis 
around  the  cicatrix,  which,  however,  continued  firm  and  healthy. 

1.  The  Sciri'hous  Wa7't  is  usually  of  the  natural  color  of  the  skin,  but 
sometimes  of  a  reddish  or  dark  grayish  hue,  hard,  and  somewhat  irregu¬ 
lar  in  shape.  It  may  remain  for  a  long  time  stationary,  but  at  last 
ulcerates  and  spreads  rapidly,  giving  rise  to  vast  destruction  of  parts ; 
the  ulcers  formed  by  it  presenting  the  characters  of  cancer,  with  a  hard 
base,  everted  edges,  and  foul  surface. 

2.  The  Infiltrated  Cancer  of  the  skin  occurs  in  the  form  of  a  flat, 
dark,  irregularly  defined  induration,  which  scabs  over  with  dark,  rugged, 
grayish-brown  incrustations,  having  shooting  pains  in  and  around  it,  and, 
after  remaining  stationary  perhaps  for  years,  runs  into  ulceration,  and 


NEURITIS. 


737 


rapicllj^  destro3"S  the  parts  it  affects.  After  ulceration  has  been  set  up, 
the  patient’s  life,  according  to  Walshe,  is  seldom  prolonged  be3^ond  two 
years.  Enc&phaloid  Cancer  of  the  skin  is  of  rare  occurrence,  but  occa- 
sionall3^  forms  large  fungatiug  masses  sprouting  from,  and  solel3"  con¬ 
nected  with,  this  tissue. 

3.  Cancerous  Ulcers  of  the  skin  may  arise  from  any  local  irritation  ; 
or  an  unhealth3^  and  specific  action  may  be  set  up  in  an  old  scar  or  ulcer, 
and  cause  it  to  assume  a  cancerous 
character  (Fig.  251).  These  cancer¬ 
ous  ulcers  may  indeed  occur  upon 
almost  an3^  part  of  the  bod3^ ;  I  have 
seen  them  on  the  back,  breast,  fingers, 
hand,  thigh,  and  sole  of  the  foot. 

They  are  flat,  gra3^,  or  sloughy-look¬ 
ing,  often  wdth  large  warty  granula¬ 
tions  and  protuberant  masses,  a  good 
deal  of  induration  about  them,  and 
but  little  discharge.  Their  structure 
is  usuall37'  that  of  scirrhus,  but  not  unfrequentl3^  melanotic  deposits  and 
masses  of  melanoma  are  deposited  in  them,  and  the  neighboring  epidermis 
may  be  black  in  patches  from  melanotic  deposits. 

The  Treatment  of  cutaneous  cancer  consists  in  its  excision,  or  in  am¬ 
putation  of  the  limb  affected.  Its  removal  b3^  excision,  whether  in  the 
form  of  wart,  crust,  or  ulcer,  should  be  effected  as  soon  as  its  true  cha¬ 
racters  have  declared  themselves;  provided  it  be  of  such  a  size,  and  so 
situated,  that  it  can  be  freely  removed  with  a  suflicient  stratum  of  sub¬ 
jacent  healthy  parts,  and  a  wide  border  of  surrounding  skin.  Should  it 
be  so  situated  that  its  excision  through  surrounding  health3^  tissue  is 
not  practicable,  the  limb  must  be  amputated,  as  was  done  in  the  case 
depicted  in  Fig.  251.  In  such  circumstances  the  limb  ma3'  be  removed 
at  no  great  distance  above  the  disease ;  it  not  being  necessary,  as  in 
cases  of  cancer  of  the  extremities  where  the  bones  are  affected,  to  allow 
a  joint  to  intervene  between  the  seat  of  operation  and  the  malignant 
growth. 


Fig.  251. 


Cancerous  Ulcer  of  the  Leg. 


CHAPTER  XXXVIII. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

NEURITIS. 

Inflammation  of  the  Nerves,  or  rather  of  the  Neurilemma,  is  not  of 
veiy  unfrequent  occurrence,  being  usuall3’'  the  result  of  rheumatism,  of 
wounds,  or  of  strains.  When  Neuritis  is  rheumatic,  it  principally  affects 
the  nerves  of  the  face  and  the  low^er  extremit3". 

Symptoms. — These  consist  of  tenderness  on  pressure  along  the 
course  of  the  nerve,  and  severe  continuous  pains  running  down  its 
trunk  and  ramif3dng  along  its  branches,  with  occasional  violent  exacer¬ 
bations,  especially  on  moving  or  touching  the  part,  and  at  night ;  there 
are  usuall3'  swelling  along  the  course  of  the  trunk,  and  some  consti¬ 
tutional  pyrexia.  When  chronic,  this  condition  may  readil3'’  be  con¬ 
founded  with  neuralgia ;  of  which,  indeed,  it  constitutes  one  variet3^ 
VOL.  I. — 47 


738 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


On  examination  after  death,  the  sheath  of  the  nerve  will  be  found 
injected  and  swollen,  and  the  nervous  tissue  softened. 

Treatment. — This  consists  in  the  emplo3’ment  of  anti-inflammatory 
means ;  cupping  or  the  application  of  leeches,  according  to  situation, 
poppy  or  belladonna  fomentations,  and  local  emollients.  When  the 
neuritis  is  rheumatic,  the  acetous  extract  of  colchicum  is  the  best  remedy*; 
when  it  is  more  chronic  and  nocturnal,  iodide  of  potassium,  either  alone 
or  in  combination  with  sarsaparilla,  ma^’  advantageous!}-^  be  given. 

NEURALGIA. 

Neuralgia  frequently  occurs  in  surgical  practice,  either  complicating 
other  diseases,  or  as  a  distinct  affection  simulating  closely  various  or¬ 
ganic  lesions,  more  especially  of  joints  and  bones. 

Symptoms. — The  pain  in  neuralgia  is  the  essential  symptom,  and,  in 
fact,  constitutes  the  disease  itself.  It  may  be  of  two  kinds;  either  fol¬ 
lowing  anatomically  the  course  of  a  nerve  and  the  distribution  of  its 
filaments  ;  or  affecting  a  considerable  portion  of  the  surface  without 
reference  to  any  special  nerve.  It  is  of  all  degrees  of  severity,  some¬ 
times  moderate,  sometimes  unendurable,  even  by  those  who  possess  the 
greatest  fortitude  ;  w^hen  severe,  it  usually  comes  on  suddenly,  with  a  kind 
of  shock,  and  continues  of  a  sharp,  darting  or  tearing  character,  coursing 
along  the  trunk  or  ramifications  of  the  affected  nerve,  the  distribution  of 
w’hich  may  often  be  distinctly  indicated  by  the  direction  the  pain  takes. 
It  is  often  accompanied  by  other  sensations,  such  as  a  tickling,  smarting, 
or  creeping  feeling  on  the  affected  surface;  in  some  instances  relieved  by 
pressure,  in  others  increased  by  the  slightest  touch  or  movement  of  the 
part.  Occasionally  there  is  spasm  in  the  muscles  supplied  by  the  affected 
nerve ;  in  other  cases,  there  are  heat  and  redness  of  the  surface,  with 
increased  secretion  from  the  neighboring  organs,  as  a  fiow  of  saliva  or 
tears  when  the  nerves  of  the  jaw  or  eye  are  implicated.  The  duration 
of  an  attack  may  vary  from  a  few  moments  to  many  days  or  months. 
The  pain  is  most  commonly  intermittent  or  remittent ;  it  is  often  irregu¬ 
larly  so,  but  in  some  instances  the  periodicity  is  well  marked. 

Situations. — This  disease  may  affect  almost  any  part  of  the  body ;  it 
is  most  commonly  seated  distinctly  in  the  trunk  and  branches  of  a  nerve. 
The  divisions  of  the  fifth  pair  are  the  most  frequent  seat  of  neuralgia;  the 
i:)ain  may  extend  to  the  whole  of  the  branches  of  this  nerve  on  one  side 
of  the  head  and  face,  but  more  commonly  it  is  confined  to  one  of  its 
principal  divisions,  such  as  the  infraorbital,  which  is  especiaily  liable  to 
be  affected  ;  in  many  instances  it  is  seated  in  the  temporal  and  dental 
nerves.  Not  unfrequently  some  of  the  terminal  twigs  alone  of  one  of 
these  nerves  become  the  seat  of  intense  pain ;  thus  occasionally  the 
affection  is  found  limited  to  a  patch  on  the  cheek,  brow,  or  temple,  from 
w'hich  it  scarcely  ever  shifts.  The  posterior  branches  of  the  dorsal  spinal 
nerves,  and  the  intercostals,  are  also  very  commonly  affected,  though  not 
to  the  same  extent  as  the  fifth  pair.  In  other  cases  the  w^hole  of  an  organ, 
or  part,  becomes  the  seat  of  neuralgia,  though  no  one  nerve  may  appear 
to  be  distinctly  implicated :  thus  the  testes,  the  breast,  the  uterine  organs, 
or  one  of  the  larger  joints,  as  the  hip  or  knee,  are  occasionally  the  seats 
of  severe  suffering  of  this  kind.  Extreme  cutaneous  sensibility  is  a 
marked  feature  in  some  cases  ;  the  patient  wincing  and  suffering  severely 
w^henever  tbe  skin  is  pinched  or  touched,  how'ever  lightly. 

Causes. — The  causes  of  this  painful  disease  are  very  various ;  they 
may  be  constitutional  or  local.  It  seldom  occurs  in  strong  and  healthy 


DIAGNOSIS  AND  TEEATMENT  OF  NEURALGIA.  789 


individuals,  but  is  almost  invariabl}^  associated  with  want  of  power,  unless 
it  be  occasioned  b}^  some  local  mechanical  cause.  Depressing  influences 
of  all  kinds  are  especially'  apt  to  produce  it ;  thus,  debilitating  diseases, 
mental  depression,  and  particularly  exposure  to  malaria,  are  common 
occasioning  causes  ;  those  forms  of  the  disease  that  arise  from  malarial 
influences,  or  from  exposure  to  simple  cold  and  w’et,  usually  assume  a 
very  intermitting  or  periodical  character,  and  are  commonly  seated  in 
the  nerves  of  the  head.  The  hysterical  temperament  very  frequently 
disposes  to  the  spinal  and  articular  forms  of  neuralgia.  There  is  no 
constitutional  condition  with  which  neuralgia  is  more  frequently  asso¬ 
ciated  than  with  anaemia  :  hence  its  frequency  in  females.  As  Romberg 
somewhat  poetically  says,  “  Xeuralgia  is  the  pray^er  of  the  nerve  for 
healthy  blood.”  Various  sources  of  pei'ipheral  ii'ritation^  as  loaded 
bowels,  the  irritation  of  w'orms,  carious  teeth,  uterine  disease,  and  cal¬ 
culus,  may  be  recognized  as  producing  some  of  the  more  obscure  varieties 
of  the  disease. 

Neuralgia  may  also  arise  from  any  compression  exercised  upon  the 
trunk  of  a  nerve ;  and  in  this  way,  indeed,  some  of  the  more  intractable 
forms  of  the  affection  have  their  origin.  Thus,  thickening  of  the  neuri¬ 
lemma,  the  pressure  of  a  tumor  of  any  kind,  or  of  a  piece  of  dead  bone, 
may  give  rise  to  the  most  intense  pain  in  the  part  supplied  by  the  irri¬ 
tated  nerve  ;  and  it  is  not  improbable  that,  in  many  of  the  cases  of  neural¬ 
gia  in  the  branches  of  the  fifth  nerve,  pain  may  be  owing  to  periosteal 
inflammation,  or  to  some  other  disease  of  the  osseous  canals  through 
which  the  divisions  of  the  nerve  pass. 

Diagnosis. — The  diagnosis  of  neuralgia,  though  usually  effected 
without  any  difficulty,  is  in  some  cases  a  little  embarrassing,  as  the  pain 
may  occasionally  simulate  that  of  organic  disease  or  inflammation  of  the 
part.  From  organic  disease  of  the  part  that  is  the  seat  of  suffering,  such 
as  the  hip,  the  knee,  the  testis,  or  the  breast,  this  disease  may  usually 
be  distinguished  by  the  coexistence  of  cutaneous  sensibility,  the  exist¬ 
ence  of  the  hy’sterical  temperament,  and  the  absence  of  the  other  signs 
that  would  accompany  lesions  of  structure  in  the  part  affected.  From 
inflammation  the  diagnosis  is  usually”  sufficiently  easy”,  by  attending  to 
the  intermittent  character  of  the  neuralgic  pain,  to  its  occurrence  in  hys¬ 
terical  temperaments,  and  to  the  absence  of  the  constitutional  symptoms 
of  inflammation.  But  occasionally”,  when  local  inflammatory  irritation 
is  conjoined  with  the  neuralgia,  the  diagnosis  is  truly  difficult.  Here 
the  presence  of  cutaneous  sensibility”  and  the  relief  of  the  pain  by  firm 
pressure  will  indicate  neuralgia ;  whereas,  in  inflammation,  there  is  no 
tenderness  of  surface,  but  the  suffering  is  aggravated  by  deep  pressure. 

Treatment. — The  treatment  of  neuralgia  must  have  reference  to  the 
cause  of  the  disease,  and  will  be  successful  or  not  according  as  this  may” 
be  more  or  less  readily”  removed.  So  long  as  the  conditions  that  prima¬ 
rily  occasion  the  disease  subsist,  the  pain  is  likely  to  continue :  and  if 
these  conditions  be  irremovable,  the  disease  may  be  looked  upon  as  neces¬ 
sarily  incurable,  though  the  suffering  may  be  alleviated  by  appropriate 
means.  When  it  arises  from  any  central  nervous  affection,  there  may  be 
fear  of  the  ultimate  occurrence  of  disease  of  a  more  serious  type,  such  as 
epilepsy,  insanity,  &c. 

When  it  occurs  as  the  consequence  of  anaemia,  or  in. the  hysterical 
temperament,  the  administration  of  the  more  stimulating  and  stronger 
preparations  of  iron,  such  as  the  sulphate  or  the  sesquichloride,  or  Rie 
mistura  ferri  composita,  either  alone  or  in  combination  with  quinine, 
with  attention  to  the  state  of  the  bowels,  and  of  the  uterine  functions, 


740 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


and  a  general  tonic  regimen  calculated  to  brace  and  improve  the  general 
health,  such  as  sea-bathing,  the  cold  douche,  or  sponging,  will  be  of 
essential  service.  In  some  of  these  cases  the  combinations  of  zinc,  espe- 
ciall}"  the  valerianate,  with  the  fetid  gums,  will  remove  the  disease  when 
iron  does  not  influence  it  much.  At  the  same  time,  the  application  or 
inunction  of  belladonna  or  aconite  plasters  and  liniments  may  be  of 
service.  When  the  neuralgia  is  distinctly  periodical,  quinine  in  full 
doses,  or  the  liquor  arsenicalis,  will  usualty  effect  a  speed}'  cure.  When 
it  is  rheumatic,  occurring  in  debilitated  subjects,  and  attended  b}'  dis¬ 
tinct  nocturnal  exacerbations  of  pain,  no  remedy  exercises  so  great  an 
impression  upon  it  as  the  iodide  of  potassium,  especially  when  adminis¬ 
tered  in  combination  with  quinine. 

In  the  more  severe  and  protracted  forms  of  the  disease,  relief  may  be 
occasionally  obtained  b}^  attention  to  the  state  of  the  liver  and  digestive 
organs,  b}'  a  course  of  some  of  the  more  purgative  mineral  waters,  and 
b}'  the  occasional  administration  of  aloetics  or  croton  oil,  followed  by 
tonic  remedies. 

Local  applications  of  a  sedative  kind,  such  as  chloroform,  belladonna, 
aconite,  opium,  &c.,  are  often  useful  adjuncts  to  constitutional  treat¬ 
ment.  By  far  the  readiest  mode  of  afifording  relief  locally  is  the  “hypo¬ 
dermic  injection”  introduced  by  Wood  of  Edinburgh.  This  consists 
in  injecting  a  few  drops  of  a  strong  solution  of  morphia  under  the  skin 
of  the  part  affected,  by  means  of  the  hypodermic  syringe.  Xot  more 
than  from  one-third  to  half  a  grain  of  morphia  should  at  first  be  used  at 
one  time,  and  the  action  of  this  small  dose  is  often  very  powerful.  More 
than  this,  it  is  unsafe  to  begin  with  ;  but  the  quantity  ma}'  be  enor- 
mousl}'  increased.  I  have  a  patient  who,  to  relieve  the  pains  attending 
cancer  of  the  anus,  requires  no  less  than  six  grains  to  be  injected  every 
twelfth  hour.  In  some  cases  a  single  injection  has  cured  neuralgia  which 
has  resisted  all  other  means. 

In  many  cases  all  these  means,  however,  are  unfortunatel}^  unavailing, 
and  the  sufferer  is  doomed  to  an  existence  of  almost  constant  pain,  except 
at  times  when  the  disease  appears  to  cease  of  itself,  or  has  its  intensity 
blunted  by  the  administration  of  the  more  powerful  sedatives,  such  as 
morphia  hj'podermically,  or  veratria,  aconite,  or  atropine  externally.  In 
these  distressing  cases  the  sufferer  is  ready  to  grasp  at  any  means  of 
relief  that  is  held  out  to  him  ;  and  section  of  the  affected  nerve  is  not 
unfrequentl}'  recommended  as  a  last  chance  of  the  removal  of  the  disease. 
It  is  clear,  however,  that  such  an  operation,  though  occasionally  produc¬ 
tive  of  temporary  relief,  cannot  in  most  cases  be  expected  to  benefit  the 
patient  permanently  ;  for  by  it  the  cause  of  the  neuralgia  is  not  removed, 
and  it  can  consequently  only  be  of  service  when  the  pain  is  peripheral, 
occasioned  by  some  local  irritation  existing  between  the  part  cut  and  the 
terminal  branches  of  the  nerve.  If  the  neuralgia  depend  on  s.ny  central 
cause,  or  on  local  irritation  existing  higher  up  than  the  point  divided, 
the  operation  must  eventuall}'  be  useless.  Thus,  if  the  source  of  irri¬ 
tation  exist  in  the  terminal  branches  of  the  infraorbital  nerve,  the  divi¬ 
sion  of  this  trunk  might  be  useful ;  but  if  the  pain  be  occasioned  by 
any  pressure  to  which  this  nerve  may  be  subjected  in  its  passage  through 
its  canal  by  a  carious  state  of  the  bones,  or  b}'  disease  of  the  periosteum, 
it  would  be  unavailing;  though  it  is  a  remarkable  fact,  that  it  not  unfre- 
quentl}'  happens  that  there  is  after  these  operations  a  temporary  cessa¬ 
tion  in  the  pain  for  a  few  weeks  or  months.  In  some  of  these  cases, 
however,  the  pain  shifts  its  seat  from  the  branch  operated  on  to  another 
division  of  the  same  trunk  ;  thus,  if  the  infraorbital  have  been  divided. 


TREATMENT  OF  NEURALGIA. 


741 


the  inferior  dental  or  submental  nerve  becomes  the  seat  of  pain.  Or 
this  may  ascend,  as  it  were,  to  the  point  at  which  the  nerve  was  divided  ; 
thus,  after  amputation  for  neuralgia  of  the  knee,  the  pain  may  return 
in  the  stump,  and  again  when  this  is  removed  a  second  or  even  a  third 
time. 

The  nerves  on  which  section  has  been  most  frequently  performed  are 
the  different  branches  of  the  fifth — the  infraorbital,  the  inferior  dental, 
and  the  submental.  Should  it  ever  be  thought  necessary  to  do  it,  it 
would  be  proper  not  only  to  divide  the  nerve,  but  to  excise  a  portion  of 
it;  otherwise  reunion  will  speedily  take  place,  and,  the  continuity  of  the 
nerve  being  re-established,  the  operation  will  fail.  The  procedure,  when 
applied  to  the  infraorbital  and  the  submental  nerves,  simply  consists  in 
cutting  down  on  the  trunk  where  it  escapes  from  the  foramen,  isolating 
and  dissecting  out  a  portion  of  it ;  in  doing  this,  no  great  difficulty  can 
be  experienced  by  aii}^  one  possessing  moderate  anatomical  knowledge. 
Langenbeck  has  proposed  excision  of  that  part  of  the  infraorbital  nerve 
which  lies  in  the  orbit.  A  tenotomy-knife  is  carried  along  the  outer  wall 
of  the  orbit,  and  the  nerve  is  divided  where  it  escapes  from  the  spheno¬ 
maxillary  fissure.  An  incision  having  been  made  over  the  inferior  infra¬ 
orbital  foramen,  the  nerve  is  drawn  out  and  cut  off. 

Facial  Neuralgia  more  frequently  takes  its  origin  in  the  irritation  of 
a  dental  nerve  than  in  any  other  branches  of  the  fifth.  This  necessarily 
arises  from  the  frequency  with  which  the  terminal  branches  of  these 
nerves  become  irritated  in  consequence  of  the  presence  of  carious,  broken, 
inflamed,  or  overcrowded  teeth ;  and  on  the  removal  of  these  local  and 
eccentric  causes  of  irritation  the  pain  usually  ceases.  There  is,  however, 
one  form  of  neuralgia  of  the  dental  nerve  that  is  so  severe  and  so  per¬ 
sistent  in  its  general  duration,  and  so  paroxysmal  in  its  attacks,  that  it 
constitutes  a  true  Tic.  This  neuralgia  may  affect  either  jaw.  I  have 
most  frequently  met  with  it  in  the  lower,  and  more  commonly  in  women 
than  in  men.  It  occurs  in  people  who  have  lost  teeth ;  and  the  pain, 
which  is  excessively  acute  and  paroxysmal,  commences  in  and  darts 
from  the  contracted  alveoli  and  the  condensed  and  indurated  gum 
covering  them.  It  appears  to  be  owing  to  the  compression  of  the  ter¬ 
minal  branches  of  the  dental  nerves  by  the  contraction  upon  tliem  of 
the  empt}^  alveoli.  Taking  this  view  of  the  pathology  of  this  form  of 
neuralgia,  I  have  treated  it  by  the  removal  of  a  portion  of  the  indurated 
alveolar  border  and  gum.  Some  3"ears  ago  I  did  this  in  a  patient  of 
Dunn’s,  removing  a  V'Shaped  piece  of  the  bone  by  means  of  a  Hey’s  saw; 
and  more  recently,  I  have  in  addition  clipped  away  the  bone  by  means 
of  cutting  pliers.  Gross,  who  has  directed  attention  to  this  form  of 
neuralgia,  uses  the  pliers  only  for  the  removal  of  the  affected  bone.  In 
any  case  it  is  necessary  to  cut  into,  but  not  through,  the  body  of  the 
bone.  By  this  incision,  the  dental  canal  may  be  opened  in  the  body  of 
the  bone,  and  the  nerve  destroyed  by  means  of  the  galvanic  cautery. 
The  inferior  dental  nerve  has  in  some  cases  of  intense  and  persistent 
neuralgia  been  divided  by  a  veiy  ingenious  operation.  This  consists  in" 
dissecting  up  a  flap  over  the  ramus  of  the  lowei*  jaw,  appljdug  a  trephine 
to  the  bone  so  exposed,  and  cutting  out  a  portion  of  it  over  that  part 
where  the  nerve  enters  the  dental  canal,  which  is  thus  laid  bare  ;  when 
a  portion  of  the  nerve  maybe  excised,  by  being  raised  on  a  director,  and 
snipped  away  with  scissors. 


742 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


NEUROMA. 

By  Neuroma  is  meant  a  tumor  connected  with  a  nerve.  This  tumor 
may  vary  from  the  size  of  a  millet-seed  to  that  of  a  melon ;  it  is  usually 
solid  and  composed  of  fibrous  tissue  ;  but  when  it  attains  a  large  bulk, 
a  cavity  may  form  in  it,  containing  a  yellowish  or  brownish  serous- 

looking  fluid,  apparently  owing  to  the  disintegration 
of  the  central  portions  of  the  mass.  In  shape  it  is 
usually  oval  or  oblong,  the  long  axis  corresponding 
to  the  course  of  the  nerve  (Fig.  252) ;  it  grows  slowly, 
and  is  movable  transversely,  but  not  in  the  direction 
of  the  nervous  trunk  on  which  it  is  seated  ;  it  has  no 
appearance  of  malignancy,  and,  however  large  it 
becomes,  it  never  contracts  adhesions  to  the  integu¬ 
ment  nor  involves  its  structure.  Neuroma  commonly 
only  affects  the  nerves  of  the  cerebro-spinal  system  ; 
but  Berard  has  met  with  one  case  of  the  disease  on  a 
ganglionic  nerve.  The  nerves  of  special  sense  are 
but  very  rarely  the  seat  of  this  disease.  Indeed,  the 
only  recorded  case  with  which  I  am  acquainted  of  a 
neuroma  connected  with  one  of  these  nerves,  is  one 
described  by  Lidell  of  New  York,  of  a  neuroma  of  the 
optic  nerve  filling  up  the  orbit,  flattening  and  pro¬ 
truding  the  e3’’e,  and  extirpated  together  with  the 
contents  of  the  orbit  bj^  that  Surgeon. 

Most  commonly  the  tumor  is  single,  and  then  is 
usuallj^  attended  with  very  severe  lancinating  or  neu¬ 
ralgic  pain,  which  extends,  however,  only  to  the  parts 
below  the  tumor,  and  is  commonly  parox^-smal.  This 
pain  is  evidently  owing  to  the  stretching  of  the 
nervous  twigs  as  they  pass  along  the  convexity  of  the 
growth.  When  single  and  painful,  the  tumor  com¬ 
monly  goes  by  the  name  of  the  Painf  ul  Subcutaneous  Tubercle^  and  is 
then  usually  met  with  from  the  size  of  a  pin’s  head  to  that  of  a  cherry¬ 
stone,  commonly  seated  upon  the  limbs,  and  most  frequently  in  connec¬ 
tion  Avith  one  of  the  nerves  of  the  lower  extremity  :  but  it  may  be 
situated  upon  the  arm,  the  trunk,  or  even  on  the  scrotum  and  cheek, 
where,  however,  it  is  not  so  commonly  met  with.  Wherever  a  single 
neuroma  occurs,  it  is  acutely  and  intolerablj’’  painful  on  being  touched, 
and  is  usually  tender  as  well.  It  is  a  very  remarkable  fact  that,  though 
neuromatous  tumors  Avhen  single,  or  when  but  two  or  three  exist,  are 
most  acutel^^  painful,  yet,  when  the^^  are  generally  diffused  over  the  body, 
they  lose  their  sensibilit}",  and  are  unattended  by  any  inconvenience 
except  such  as  arises  from  their  numbers  and  bulk.  The  number  of 
masses  thus  formed  is  often  amazingl}^  great ;  thus,  in  one  of  R.  W. 
Smith’s  cases,  described  in  a  monograph  which  contains  the  fullest  and 
most  accurate  account  of  this  disease,  he  counted  in  the  two  lower  ex¬ 
tremities  alone  more  than  250  of  these  tumors,  besides  those  in  other 
parts  of  the  body.  In  another  case  related  b}^  him,  there  were  upwards 
of  200  small  neuromata  scattered  over  the  sides  of  the  chest  and  abdo¬ 
men,  450  on  the  right  low^er  extremity,  and  upwards  of  300  on  the  left ; 
altogether  probably  not  less  than  2000  of  these  growths  in  “  this  unpre¬ 
cedented  case.” 

Structure. — The  painful  subcutaneous  tubercle  is  composed  of  a 
white  or  grajush  fibrous  mass  developed  in  the  neurilemma,  and  having 


Fig.  252. 


Neuroma  Avith  Nervous 
Filaments  spread  out 
over  Tumor. 


1 


TRAU^IATIC  PARALYSIS. 


743 


nervous  filaments  stretched  through  or  over  it.  The  nervous  trunk 
above  and  below  the  tumor  is  normal;  it  is  only  where  it  comes  into 
contact  with  the  neuroma,  and  is  exposed  to  its  pressure,  that  it  under¬ 
goes  the  change  indicated. 

Traumatic  Neuromata  may  arise  from  the  wound  or  partial  division 
of  nerves,  and  occasion  the  most  intense  agony.  Sometimes  growths 
of  this  description  of  a  fusiform  shape,  and  varying  from  a  cherry-stone 
to  a  pigeon’s  egg  in  size,  are  met  with  in  stumps  after  amputations ;  in 
many  instances  they  are  unattended  by  inconvenience,  but  occasionally 
give  rise  to  very  severe  pain. 

Treatment. — The  treatment  of  j^ainful  neuromata,  whether  of  an 
idiopathic  or  traumatic  character,  or  existing  in  stumps,  consists  in  their 
excision.  After  removal,  the  part  supplied  by  the  nerve,  which  is  usu¬ 
ally  necessarily  divided,  becomes  paralyzed  for  a  time,  but  may  eventu¬ 
ally  regain  its  sensibility.  In  some  cases,  however,  by  cautious  dissec¬ 
tion,  the  tumor  may  be  removed  from  the  nerv^e  that  is  in  contact  with 
it,  without  cuttinor  this  across.  This  has  been  done  in  the  case  of  neuro- 

/  o  _ 

mata  of  the  sciatic  nerve  and  its  divisions.  When  these  tumors  are  nu¬ 
merous,  they  should  not  be  interfered  with;  and  if  unattended  by  pain, 
they  need  not  be  excised  unless  their  bulk  prove  inconvenient. 

TRAUMATIC  PARALYSIS. 

Traumatic  paralysis  is  referable  to  four  distinct  sets  of  causes.  First, 
At  may  arise  from  Compression  of  the  Brain  giving  rise  to  hemiplegial 
or  more  general  paralj^sis,  according  as  to  whether  the  cause  of  pressure 
be  confined  to  one  side,  or  extend  to  the  brain-substance  generally,  so  as 
to  injure  or  influence  it  more  widely.  Secondly,  it  ma}"  arise  from  Injury 
of  the  Spinal  Gord^  giving  rise  primarily  or  secondarily  to  lesion  of  the 
substance,  either  by  laceration,  compression,  or  ultimate  disintegration, 
paraplegia  of  the  parts  below  the  seat  of  injury  being  the  result.  Thirdly, 
Pressure  on  a  Nerve  or  nerves  at  any  part  of  their  course,  from  their 
roots  to  the  terminal  subdivision  of  their  trunk,  may  occasion  paralysis 
of  the  parts  supplied  by  them.  Fourthly,  Section  of  a  Nerve  will  neces- 
sarity  destroy  all  sensation  and  motion  in  the  part  to  which  it  is  dis¬ 
tributed.  From  whatever  cause  it  arises,  traumatic  paralysis  may  pre¬ 
sent  every  possible  amount  of  diminution  of  nervous  power,  from  the 
slightest  impairment  of  sensation  or  of  -motion  in  a  limb,  to  complete 
annihilation  of  both.  But  not  only  does  the  actual  degree  of  loss  of  sen¬ 
sory  or  motor  power  vary  greatly,  but  the  relative  degree  of  impairment 
of  sensation  and  of  motion  is  equally  variable.  In  the  great  majority  of 
cases  both  are  tolerabl}^  equally  affected.  But,  in  not  a  few  instances, 
the  diminution  of  one  far  exceeds  that  of  the  other.  Thus  the  motor 
power  may  to  a  great  extent  be  lost  in  a  part,  whilst  sensation  appears 
to  be  normal.  But  this  is  often  more  apparent  than  real;  for  a  diminu¬ 
tion  of  motor  power,  however  trifling,  is  at  once  perceived ;  whilst  an 
impairment  of  sensation,  even  though  considerable,  ma}''  long  escape  de¬ 
tection.  Hence  it  is  that  motion  seems  to  be  more  frequentl}^  lost  than 
sensation,  though  the  latter  may  be  equally  impaired.  A  person  who 
sufiers  from  a  slight  degree,  however  trifling  it  may  be,  of  impairment  of 
motion  or  of  want  of  harmony  between  the  action  of  the  muscles  of  a 
part,  may  not  be  conscious  of  this  while  at  rest,  but  it  manifests  itself 
unmistakably  when  he  brings  the  part  into  movement;  whilst  neither  he 
nor  others  may  be  capable  of  observing  the  corresponding  loss  of  sensi¬ 
bility  unless  it  be  most  minutely  and  accurately  tested.  But  not  only 


744 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


may  sensation  and  motion,  one  or  both,  be  impaired  or  lost,  but  the  more 
complete  loss  of  one  of  these  may  be  associated  with  an  exaltation  of  the 
other.  Thus  there  may  be  loss  of  motion  in  a  part,  Avitli  increased  or 
nervous  sensibility  of  it ;  in  these  circumstances,  instead  of  being  relaxed 
and  soft,  as  is  the  case  when  there  is  anaesthesia,  it  is  most  commonly 
rigidly  contracted,  hard  and  resistant,  a  species  of  neuralgic  paralysis 
being  developed.  Or  the  converse  condition  may  exist,  and  loss  of  sen¬ 
sation  more  or  less  complete  ma}''  be  associated  with  muscular  tremor  or 
spasm. 

1.  Paralysis  from  Compression  or  Injury  of  the  Brain  (vide  Chapter 
XXIY.)  may  be  occasioned  by  pressure  primarily  exercised  on  the  sur¬ 
face  of  the  organ,  as  by  a  portion  of  depressed  bone,  of  clotted  blood,  or 
foreign  body  of  any  kind ;  or  it  may  arise,  secondarily,  as  the  result  of 
inflammatory  effusion,  of  softening  and  disintegration  of  the  cerebral 
tissue,  and  consequent  effusion  of  blood  into  its  interior.  It  need  scarcely 
be  said  that,  the  more  a  compressing  cause  is  localized  to  one  hemisphere, 
the  more  likelihood  will  there  be  of  the  paralytic  symptoms  assuming 
the  hemiplegic  character,  affecting  the  side  opposite  to  that  injured.  The 
more  general  the  compression,  and  the  more  it  implicates  the  base  of  the 
brain,  the  greater  the  probability  of  the  paralysis  being  more  or  less 
general.  So  these  forms  of  paralysis,  when  secondary  or  remote,  de¬ 
pending  on  lesion  of  the  brain-substance,  of  a  disintegrating  character, 
are  often  mixed  up  wdth  many  symptoms  that  point  to  the  coexistence 
of  chronic  forms  of  meningeal  inflammation,  and  also  a  series  of  complex 
phenomena  that  are  not  very  easily  unravelled. 

2.  Those  forms  of  paralysis  that  arise  from  Injury  of  the  Spinal  Cord 
maj^  either  be  primaiy,  depending  on  its  compression  or  section,  or  more 
or  less  complete  destruction,  as  in  fractures  or  dislocation  of  the  spine, 
or  its  complete  compression  by  intraspinal  meningeal  hemorrhages  ;  or 
thej^  may  be  secondary  and  due  to  more  or  less  rapid  and  complete  soft¬ 
ening  and  disintegration  of  the  cord,  as  the  result  of  impairment  of  the 
nutrition  dependent  on  changes  due  to  inflammatoiy  mischief  extending 
to  it  from  its  membranes,  or  originating  in  it  as  the  direct  consequence 
of  injury.  In  all  these  cases,  the  paralysis  partakes  of  the  paraplegic 
character.  The  degree  to  which  it  extends  will  necessarily  depend  on 
the  more  or  less  complete  involvement  of  the  cord  by  the  injuiy,  or  the 
depth  of  its  disintegration  by  disease.  There  may  onl}'-  be  a  very  slight 
impairment  or  loss  of  harmony  of  motor  power  in  the  limbs,  or  there  may 
be  any  increase  of  this  impairment  up  to  complete  loss  of  all  motion  and 
sensation  in  them.  In  many  cases  the  sphincters  of  the  bladder  and 
anus  are  unaffected  or  they  may  completely  lose  all  controlling  power. 
These  forms  of  paralysis  often  affect  the  two  lower  limbs  very  unequall}’’, 
both  as  to  the  extent  of  the  loss  of  sensation  and  motion,  and  as  to  the 
impairment  of  one  power  rather  than  the  other  in  one  or  other  of  the 
extremities.  The  symptoms  vary  from  a  simple  drag  of  the  foot,  with 
no  appreciable  loss  of  sensation,  to  complete  inability  to  walk  or  even 
to  stand,  and  to  absolute  insensibility  to  the  application  of  the  most 
powerful  galvanic  stimulant.  These  forms  of  spinal  paralysis,  when 
arising  primarily  from  injury  to  the  vertebral  column,  more  particularly 
from  its  fracture,  are  often  associated  with  intense  neuralgic  pains,  wdiich 
dart  along  the  line  of  junction  between  the  sound  and  paral^dic  parts  ; 
when  they  arise  from  secondary  inflammatory  affections  of  the  cord,  they 
may  be  attended  by  the  various  symptoms  indicative  of  myelitis,  whether 
iu  the  acute  or  the  subacute  form,  such  as  spasmodic  drawing  up  of  the 


TRAUMATIC  PARALYSIS. 


745 


great  toe,  cramps  in  the  legs,  or  neuralgic  darting,  with  abnormal  modi¬ 
fications  of  sensation  through  the  limb. 

3.  Pressure  on  a  Nerve  at  some  part  of  its  course,  between  its  origin 
and  the  termination  of  its  main  branches,  is  a  frequent  cause  of  local 
traumatic  paralysis,  often  of  a  somewhat  transitory  character.  A 
familiar  instance  of  this  is  afforded  by  the  loss  of  power,  both  sensitive 
and  motor,  that  is  often  noted  in  the  hands  and  arms  of  people  using 
and  leaning  heavily  on  crutches.  The  same  partial  paralj^sis  frequently 
accompanies  certain  forms  of  spinal  injury,  more  especially  wrenches  or 
twists  of  the  vertebral  column,  causing  effusion  into  the  structures  that 
surround  the  nerves  on  their  escape  from  it,  and  thus  inducing  compres¬ 
sion  of  their  trunks  close  to  their  origin.  The  three  nerves  that  are 
more  commonly  affected  in  this  form  of  traumatic  paralysis  are  the 
Sciatic,  the  Circumflex,  and  the  Musculo-Spiral. 

Traumatic  paralysis  of  the  sciatic  nerve  is  commonly  the  result  of 
sprain  of  the  spine  in  its  lower  part.  In  it  the  whole  nerve  is  rarely,  if 
ever,  implicated;  but  the  loss  of  innervation,  motor  or  sensoiy,  is 
usuall}^  confined  to  one  of  its  principal  subdivisions:  most  frequently 
the  external  popliteal  is  the  one  affected.  In  consequence  of  this  the 
foot  is  drawn  somewhat  inwards,  drags  on  its  outer  side,  cannot  be 
properl3^  everted,  and  thus  the  patient  acquires  a  peculiarity  of  gait 
which  is  veiy  characteristic.  In  walking,  he  does  not  advance  the  foot 
as  far  as  the  sound  one;  he  brings  it  forward  with  a  rotatory  movement, 
drawing  or  dragging  the  foot  along  the  outer  edge  and  heel.  The  limb 
generally^  is  weak,  the  patient  being  unable  to  stand  on  it  alone;  and 
most  commonly  it  is  the  seat  of  neuralgic  pains  or  of  referred  sensations 
of  an  intermitting  nature. 

When  the  circumflex  nerve  of  the  arm  is  paral3'Zed,  the  accident  has 
usuall3^  happened  from  a  blow  on  the  shoulder,  ly  which  it  has  been 
directly  and  immediatel3’’  concussed.  In  this  affection  the  deltoid  muscle 
is  the  part  that  loses  power.  The  arm  can  consequentl3’'  01113"  be  imper¬ 
fectly  raised  from  the  side,  and  the  actions  of  the  deltoid  generally  are 
low.  This  form  of  traumatic  paral3"sis  is  usually  of  a  neuralgic  character, 
and  is  in  most  cases  followed  by  atroph3" — often  of  a  rigid  form — of  the 
deltoid. 

The  signs  of  paralysis  of  the  musculo-spiral  nerve,  either  as  affecting 
its  trunk  or  its  primary  subdivisions,  have  been  so  full3"  given  at  p.  356, 
that  the3"  need  not  be  described  here.  The3"  are  necessaril3^  the  same  in 
character,  though  the3’'  ma3"  vary  in  degree,  whether  associated  with 
fracture  of  the  humerus  or  not. 

4.  Traumatic  paral3^sis  from  section  of  a  nerve  has  been  described  at 
p.  292. 

Diagnosis. — The  diagnosis  of  these  various  forms  of  paral3"sis  presents 
nothing  that  need  at  present  detain  us,  as  it  is  necessaril3'  dependent 
upon,  and  in  a  great  measure  connected  with,  the  cause  of  the  affection — 
whether  cerebral,  spinal,  or  local.  There  is,  however,  one  form  of  pa¬ 
ralysis  that  is  occasionally  confounded  with  the  traumatic  varieties, 
more  especiall3"  with  that  affecting  the  sciatic  nerve,  viz.,  the  rheumatic. 

Rheumatic  Paralysis  is  a  form  of  disease  more  frequentl3"  spoken 
about  than  met  with — that  is  to  say,  if  we  appl3"  the  term  paralysis  to 
loss  of  nervous  power  independently  of  inabilit3’'  to  use  the  limb  from 
muscular  weakness,  rigidit3",  or  pain,  or  from  similar  conditions  con¬ 
nected  with  the  joints.  Yet  there  can  be  little  doubt  that  rheumatic 
paral3^sis  dependent  on  loss  of  nervous  power  really  does  exist;  thus  it 
commonl3"  arises  from  cold  in  the  facial  nerve,  and  occasionally  in  the 


746 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


sciatic  and  its  branches.  It  is  difficult  to  assign  a  distinct  pathological 
cause  for  it:  most  probably  it  is  due  to  compression  of  the  nerve  by 
effusion  within  and  around  its  sheath. 

It  is  of  importance  to  distinguish  it  from  paralysis  arising  from  other 
causes — more  particular!}"  from  the  traumatic  forms.  This  may  usually 
be  very  readily  done  by  attending  to  two  points  :  1,  that  in  the  rheumatic 
paralysis  we  have,  as  a  rule,  coexisting  or  antecedent,  an  articular 
rheumatic  affection  of  a  chronic  form ;  and,  2,  that  in  the  rheumatic 
form  of  the  disease  the  electric  irritability  of  the  muscles  is  not  dimin¬ 
ished,  whilst  in  the  spinal  and  local  forms  it  is  materially  diminished, 
or  may  be,  indeed,  entirely  absent. 

TETANUS. 

Tetanus  is  a  disease  consisting  essentially  in  an  excited  state  of  the 
spinal  cord  and  the  medulla  oblongata,  in  fact  of  the  whole  true  spinal 
system,  giving  rise  to  painful  and  continued  spasms  of  the  voluntary 
muscles  and  the  diaphragm,  alternating  with  incomplete  relaxation,  and 
usually  terminating  fatally.  This,  which  is  one  of  the  most  serious  and 
distressing  diseases  to  which  the  nervous  system  is  liable,  is  in  the  great 
majority  of  instances  of  a  Traumatic  nature,  being  the  consequence  of 
some  wound  that  implicates  or  irritates  a  portion  of  the  peripheral 
nervous  system:  the  local  irritation  so  produced  being  propagated  to 
and  affecting  the  nervous  centres,  the  excitation  of  which  becomes  per¬ 
sistent,  and  continues  after  the  local  cause  has  been  removed,  inducing 
reflex  muscular  movements  in  various  parts  of  the  body.  The  irrita¬ 
tion  of  the  nervous  sj^stem,  however,  that  induces  tetanus,  may  arise 
from  other  sources  besides  surgical  wounds,  occasioning  the  Idiopathic 
form  of  the  disease ;  thus,  for  instance,  the  presence  of  worms  in  the 
intestinal  canal,  exposure  to  cold  and  wet,  the  ligature  of  the  umbilical 
cord  in  infants,  and  even  the  uterine  irritation  following  abortion,  have 
been  known  to  occasion  it.  These  causes,  however,  rarely  give  rise  to  it 
in  this  countiy,  and  we  must  consequent!}"  regard  it  as  a  disease  chiefly 
arising  from  traumatic  lesion  of  some  kind. 

Causes  of  Tetanus. — Tetanus  may  occur  at  all  ages^  from  the 
earliest  infancy  to  an  advanced  period  of  life.  In  hot  climates,  it  is 
common  amongst  newly  born  infants,  in  the  form  of  Trismus  Neona¬ 
torum.  In  this  country  it  rarely  occurs  at  this  very  early  period  of  life, 
but  is  common  in  young  adults.  I  have  most  frequently  observed  it 
between  the  ages  of  16  and  25,  and  after  that  in  old  people;  but  it  may 
occur  at  any  period  of  life.  It  is  far  more  common  amongst  males  than 
females — in  the  proportion  of  about  four  to  one.  Season  of  the  year 
seems  to  exercise  little  influence  over  it.  It  occurs  in  all  states  of  the 
atmosphere,  and  at  all  periods  of  the  year ;  but  is  certainly  most  com¬ 
mon  when  the  weather  is  suddenly  changeable — alternating  from  heat 
to  cold.  Indeed,  long  exposure  to  cold  and  wet,  more  particularly  after 
the  body  has  been  heated,  is  the  most  common  cause  of  tetanus  when 
it  occurs  independently  of  surgical  injury,  and  is  a  frequent  predisposing 
cause  in  persons  who  have  been  wounded. 

Tetanus  may  be  occasioned  by  injuries  that  do  not  give  rise  to  breach 
of  surface;  thus  I  have  known  it  occur  in  a  child  who  was  suddenly 
thrown  down  upon  its  back  by  another  at  play,  in  a  girl  from  a  boy 
jumping  on  to  her  back,  and  in  a  lad  by  another  striking  him  on  the 
back  by  running  a  wheelbarrow  at  him  ;  and  Reid  mentions  a  case  pro¬ 
duced  by  the  stroke  of  a  whip.  But  in  the  great  majority  of  cases,  it  is 


CAUSES  OF  TETANUS. 


747 


directly  occasioned  by  a  ivoimd  of  some  kind.  Generally  a  nervous 
twig  has  been  lacerated,  divided,  or  inflamed ;  and  this  seems  to  have 
been  the  starting  point  of  that  disturbance  of  the  spinal  system  of  nerves 
which  leads  to  the  tetanic  spasms. 

The  kmd  of  ivound,  as  well  as  its  situation,  doubtless  influences  mate¬ 
rially  the  occurrence  of  the  disease.  Though  it  certainly  more  frequently 
follows  punctured,  torn,  and  lacerated,  than  clean-cut  wounds,  3’et  it  occa¬ 
sionally  complicates  these,  even  when  they  are  made  in  surgical  opera¬ 
tions  ;  thus,  it  has  been  known  to  follow  the  removal  of  the  breast,  amputa¬ 
tion,  the  ligature  of  the  larger  arteries,  and  the  operation  for  hernia.  The 
minor  surgical  operations  also  are  not  free  from  the  possibility  of  this  dan¬ 
gerous  complication.  It  has  been  observed  after  the  operation  for  fistula 
in  ano,  the  ligature  of  piles  and  varicocele,  the  removal  of  nasal  polypi ; 
and  I  have  even  seen  a  fatal  case  resulting  from  the  introduction  of  an 
issue.  Burns  are  peculiarly  liable  to  be  followed  by  tetanus.  It  is  the 
common  belief,  both  in  the  profession  and  out  of  it,  that  wounds  of  the 
hands  and  feet,  and  more  especially  of  the  ball  of  the  thumb  and  of  the 
great  toe,  are  more  likely  to  be  followed  by  tetanus  than  those  in  other 
situations.  I  think  the  truth  of  this  opinion  may  be  doubted  ;  though 
it  is  not  improbable  that  tetanus  may  occur  more  frequently  after  inju¬ 
ries  of  these  regions  than  of  other  parts  of  the  bod}’’,  simply  because 
punctured  and  lacerated  wounds  are  more  common  here  than  elsewhere. 
It  cannot  well  be  supposed  to  be  owing  to  the  tendons  and  fascim  that 
abound  here,  as  Hunter  imagined  ;  for  it  is  seldom,  if  ever,  met  with 
after  operations  for  tenotomy,  which  are  so  commonly  practised  on  the 
foot. 

Tetanus  may  occur  in  all  constitutions — in  the  strong  and  robust,  and 
in  the  feeble  and  emaciated.  It  is  especially  apt,  however,  to  occur  in 
feeble  and  debilitated  individuals,  and,  indeed,  may  be  looked  upon  as 
a  disease  of  debility ;  hence  any  condition  that  lowers  the  tone  of  the 
nervous  system  is  especially  likely  to  occasion  it.  When  it  occurs  in 
.  persons  who  are  otherwise  strong  and  in  the  prime  of  life,  it  will  be 
found  that  they  have  been  exposed  to  causes  of  depression  influencing 
the  nervous  system.  It  is  a  loss  of  nervous  tone,  and  not  muscular 
weakness,  that  disposes  to  this  disease.  Thus,  in  tropical  climates,  as  in 
some  of  the  West  India  Islands,  and  amongst  the  marshes  of  Cayenne,  it 
occurs  with  peculiar  frequency,  the  most  trifling  scratches  or  punctures 
being  followed  by  the  disease.  Poland,  who  has  exhausted  the  statistics 
of  tetanus,  states  that  the  mortality  from  it  is  in  London  .025,  whereas 
in  Bombay  it  is  2.5  per  cent,  of  the  total  deaths.  It  is  interesting  to 
observe,  that  the  natives  of  hot  climates  are  far  more  liable  to  this  disease 
than  Europeans  resident  there. 

In  military  practice  tetanus  is  of  common  occurrence.  Its  frequency 
varies  much  in  different  campaigns  and  under  different  circumstances, 
season,  and  climate.  In  the  Peninsular  War,  it  was  estimated  to  occur  in 
the  proportion  of  about  one  case  in  every  200  wounded ;  in  the  Schleswig- 
Holstein  war  of  1849,  according  to  Stromeyer,  once  in  about  850  cases.  In 
the  Crimea  it  appears  to  have  been  of  rare  occurrence.  Alcock's  estimate 
of  one  to  every  19  wounded  is  evidently  too  hig;h.  After  naval  enorao^e- 
ments,  however,  the  mortality  has  often  been  high,  particularly  if  they 
have  taken  place  in  tropical  climates.  Sir  G.  Blane  states  that,  after 
Rodney’s  action  in  the  West  Indies,  out  of  810  wounded  20  were  attacked 
with  tetanus,  being  one  in  40.  All  European  Army-Surgeons  are  agreed, 
that  sudden  changes  from  heat  to  cold  are  amongst  the  most  frequent 
causes  of  tetanus  among  the  wounded.  Thus,  Larrey  states  that,  after 


748  ' 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  battle  of  Moskowa,  although  the  number  of  wounded  was  immense, 
there  were  few  cases  of  tetanus,  the  heat  being  very  great  and  continuous ; 
whilst  after  Bautzen,  where  the  wounded  were  left  on  the  field  all  night 
exposed  to  severe  cold,  more  than  100  had  tetanus;  and  after  the  battle 
of  Dresden,  when  great  heat  was  followed  by  much  wet  and  cold,  the 
wounded  suffered  most  severely.  So,  after  some  of  the  Indian  battles, 
as  Chilianwallah  and  Ferozepore,  where  the  wounded  lay  exposed  to  cold 
nights  after  very  hot  days  (Macleod),  tetanus  was  of  very  frequent  occur¬ 
rence.  The  case  appears  to  have  been  different  in  America,  where  tetanus 
does  not  seem  to  have  arisen  from  exposure  of  the  wounded  to  cold  and 
night- air.  Chisholm  states  that  although,  from  the  wooded  nature  of 
the  country  in  which  the  battles  were  often  fought,  wounded  men  were 
not  unfrequently  left  for  two  or  three  da3^s  on  the  ground,  tetanus  did 
not  appear  to  be  more  frequent  amongst  them  than  in  those  immediately 
cared  for.  Hennen  states  that  a  draught  of  air,  whether  hot  or  cold, 
directly"  blowing  on  the  patient,  is  the  most  fertile  cause  of  tetanus. 

The  frequency  with  which  tetanus  occurs  varies  much.  It  often  hap¬ 
pens  that  not  one  case  occurs  in  a  hospital  for  some  3’ears,  and  then 
several  are  met  with  in  close  succession  or  simultaneously-. 

Period  of  Occurrence. — Tetanus  may  take  place  at  any  period  after 
the  infliction  of  the  wound  that  occasions  it.  In  hot  climates  especially, 
it  may  occur  very  speedily ;  thus,-  Robinson  relates  the  case  of  a  negro 
servant  in  the  West  Indies,  w-ho  scratched  his  finger  with  a  broken  plate, 
and  died  of  tetanus  in  a  quarter  of  an  hour.  It  is  very  seldom,  how¬ 
ever,  in  temperate  climates,  that  it  supervenes  before  the  fourth  or  fifth 
day^,  usually  from  that  to  the  tenth  day^  Larrey,  who  had  great  expe¬ 
rience  of  this  disease  during  Napoleon’s  campaigns  in  Egypt,  met  with 
it  most  frequently- between  the  fifth  and  fifteenth  day-s  after  the  infliction 
of  the  wound.  According  to  the  experience  of  the  Surgeons  of  the  Pen¬ 
insular  War,  under  whose  observation  many  hundred  cases  came,  the 
disease  does  not  show  itself  after  the  twenty--second  day ;  but,  though 
this  may-  be  the  general  rule.  Sir  G.  Blane  has  related  a  case  in  which  it 
took  place  as  late  as  a  month  after  the  infliction  of  the  wound.  It  is 
stated  that  it  may  occur  after  the  cicatrization  of  a  wound  is  completed; 
when  this  happens,  the  disease  must  rather  be  looked  upon  as  being  idio¬ 
pathic,  accidentally-  occurring  in  a  person  who  has  been  recently-  injured. 

Forms. — Tetanus  may-  be  Acute  or  Chronic  ;  being  in  some  instances 
fatal  in  the  course  of  a  few  hours,  but  usually  lasting  for  three  or  four 
day-s.  Poland  states  that  at  Guy’s  51  per  cent,  of  the  cases  were  fatal 
before  the  fiftli  day  after  invasion.  If  the  patient  survive  this  time,  the 
disease  will  commonly  run  on  to  the  eighth  or  tenth  day-,  and  occasionally 
even  for  a  longer  period  than  this;  thus,  S.  Cooper  mentions  a  case  in 
which  it  continued  in  a  soldier  for  five  weeks  after  amputation.  The 
more  chronic  it  becomes,  the  better  is  the  chance  of  recovery- ;  indeed,  if 
the  patient  survive  the  tenth  day-,  the  prospect  of  a  favorable  issue  to 
the  case  is  materially  increased.  As  a  general  rule,  those  cases  are  the 
most  fatal  which  are  most  active  in  their  symptoms;  the  danger  being 
in  the  ratio  of  the  acuteness  of  the  attack,  both  as  to  severitv  and  also 
as  to  rapidity-  of  invasion  after  injury-. 

Symptoms. — The  invasion  of  the  disease  is  sometimes  preceded  by 
a  general  uneasiness  on  the  part  of  the  patient,  a  feeling  of  illness  or 
weakness,  or  a  sense  of  impending  mischief.  Abernethy-  was  of  opinion 
that  tetanus  was  usually  ushered  in  by  a  disturbed  state  of  the  digestive 
organs,  the  stools  being  offensive  and  indicative  of  much  gastric  irrita¬ 
tion.  When  the  disease  sets  in  gradually,  it  may  be  somewhat  difficult 


SYMPTOMS  OF  TETANUS. 


749 


of  recognition  in  its  early  stages ;  if  it  come  on  suddenly,  its  nature  is 
immediately  evident.  It  is  a  remarkable  fact  that  the  cramps  do  not 
begin  in  the  part  injured  ;  but,  wherever  this  may  be  situated,  they  are 
always  first  noticed  in  the  muscles  of  mastication,  of  the  face,  and  upper 
part  of  the  neck  ;  and  throughout,  these  and  the  muscles  of  the  respira¬ 
tion  are  principally  affected.  In  tetanus,  the  circle  of  nervous  distur¬ 
bance  is  at  first  very  limited.  It  is  confined  to  the  muscles  supplied  by 
the  motor  branch  of  the  fifth,  by  the  portio  dura  of  the  seventh  nerve, 
and  by  the  spinal  accessory.  These  nerves  appear  to  be  alone  affected; 
the  sensory  division  of  the  fifth  is  never  influenced  throughout  the  disease. 
The  spasm  may  be  confined  to  the  muscles  supplied  by  these  nerves,  as 
is  the  case  in  trismus ;  but  it  soon  spreads  to  the  true  spinal  nerves, 
being,  however,  confined  to  their  motor  divisions.  The  first  symptoms 
usually  consist  in  the  patient  feeling  a  stiffness  or  soreness  about  the 
jaws  and  throat,  being  unable  to  open  his  mouth  widely,  to  take  food  or 
drink,  the  muscles  about  the  temples,  jaw,  and  neck  feeling  stiff  and 
rigid ;  this  condition  has  given  to  the  disease  the  popular  term  of  lock¬ 
jaw,  As  the  affection  advances,  the  countenance  assumes  a  peculiar 
expression  of  pain  and  anguish,  the  features  are  fixed  or  convulsed  from 
time  to  time,  and  the  angles  of  the  mouth  drawn  up,  constituting  the 
appearance  called  the  risus  sardonicus.  When  fairly  set  in,  the  disease 
is  marked  by  spasms  of  the  voluntary  muscles  of  the  most  violent  charac¬ 
ter,  with  much  pain  and  only  partial  remissions.  The  pain  is  of  that 
kind  that  attends  ordinary  cramp  in  the  muscles,  as  of  the  legs,  and  is 
usually  very  severe.  The  spasms  are  often  jerking,  the  patient  being 
suddenly  thrown  up  or  twisted  on  one  side ;  the  breath  is  drawn  with  a 
loud  sobbing  catch  from  spasm  of  the  diaphragm,  and  from  the  same 
cause  there  is  usually  violent  pain  experienced  in  the  epigastric  region, 
darting  across  to  the  spine.  The  muscles  of  the  trunk  are  usually  affected 
next  in  order  of  frequency  to  those  of  the  head  and  neck,  the  body  being 
bent  backwards  so  as  to  form  a  complete  arch  (Opiathotonos)  ]  more 
rarely  it  is  drawn  forwards  (Emprosthotonos)  ;  and  still  less  frequently 
to  one  side.  In  some  cases  the  body  becomes  perfectly  rigid,  like  a  piece 
of  wood,  the  belly  being  drawn  in,  and  the  chest  expanded.  It  is  said 
that  in  severe  cases  the  spasms  have  been  so  violent  that  muscles  have 
been  ruptured,  teeth  broken,  and  the  tongue  lacerated.  In  the  numerous 
cases  of  tetanus  that  I  have  unfortunately  witnessed,  it  has  rarely  fallen 
to  my  lot  to  see  any  effects  of  this  kind  produced ;  the  spasms,  indeed, 
being  in  general  not  very  violent,  though  continuous  and  very  painful. 
The  only  muscles  that  I  have  seen  torn  have  been  the  recti  of  the  abdo¬ 
men. 

The  intellectual  faculties  are  not  disturbed,  and  the  mind  continues 
clear  to  the  last.  Cases  of  tetanus  occasionally  prove  fatal  without  any 
elevation  of  temperature  ;  but  in  most  instances  there  are  great  heat  of 
surface,  profuse  sweats,  and  quickness  of  pulse  ;  not  so  much  from  any 
febrile  disturbance,  but  apparently  from  the  violence  of  the  muscular 
contractions.  In  most  cases  this  symptom  is  peculiarly  marked,  especi¬ 
ally  towards  the  end  of  the  case,  when  the  temperature  may  rapidly  rise 
to  extraordinary  heights.  Thus,  Wunderlich  has  recorded  a  case  in 
which  it  reached  112.55°  Fahr.  immediately  before  death.  It  may  con¬ 
tinue  to  rise  a  few  tenths  of  a  degree  higher  after  death  in  these  cases. 
The  prolongation  of  life  appears  to  depend  greatly  upon  the  intensity  of 
the  convulsive  movements :  the  more  severe  these  are,  the  sooner  does 
death  result.  The  fatal  termination  occurs  not  so  much  from  any  great 


750 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


pb3"sical  lesion,  or  disturbance  of  important  parts,  as  from  exhaustion 
consequent  on  tlie  frequency  of  the  tetanic  spasms. 

Pathology, — There  is  surely"  nothing  more  remarkable  in  the  whole 
history  of  disease  than  that,  in  consequence  of  a  trivial  wound  inflicted 
on  a  distant  part  of  one  of  the  extremities  of  the  bodjy  an  otherwise 
apparently  health}^  man  should  be  seized  with  a  spasmodic  affection  of 
the  muscles  of  the  jaws;  that  this  spasm  should  extend  to  the  trunk  ; 
and  that  after  a  few  hours  it  should  end  in  general  convulsive  move¬ 
ments  which  will,  in  the  great  majority  of  instances,  speedily  end  in 
death.  It  might  reasonably  be  expected  that  such  a  train  of  phenomena 
would  leave  the  most  unmistakable  evidences  of  the  conditions  that  give 
rise  to  them ;  and  that  pathological  anatomy  would  at  once,  and  in  the 
clearest  manner,  enable  us  to  unravel  the  mj^sterious  bonds  that  connect 
a  graze  of  the  foot  with  a  spasm  of  the  muscles  of  the  neck  and  jaw. 
But  in  this  we  shall  be  grievously  disappointed ;  for  the  morbid  appear¬ 
ances  found  after  death  from  tetanus  throw  but  little  light  on  the  real 
nature  of  this  affection — so  little,  indeed,  that  it  is  frequently  looked 
upon  as  a  “  functional  disease.”  But  in  sa^dng  that  this  or  any  other 
disease  is  functional,  we  only  express  our  ignorance  of  its  real  cause. 
There  is  no  function  without  an  organ  to  perform  it ;  and  there  can  be 
no  derangement  of  a  function  without  a  corresponding  and  concomitant 
disorder  of  the  organ  that  produces  it.  Every  “  functional”  disease  must, 
therefore,  at  last  be  referred  to  an  organic  lesion.  The  term  “  functional” 
is  only  employed  when  we  are  not  acquainted  with  the  true  nature  of  the 
disease.  As  less  is  known  of  the  real  ph^^siology  and  patholog^^  of  the 
brain  and  spinal  cord  than  of  other  organs  of  the  body,  we  have  more 
“functional”  diseases  of  the  nervous  sj^stem  than  of  the  circulatory  or 
respiratory.  But,  as  pathological  anatomy  becomes  more  studied,  and 
as  minute  investigations  into  structure  are  entered  upon,  so  the  class  of 
so-called  “functional”  diseases  becomes  narrower.  We  do  not  speak  of 
“  functional”  coma,  because  we  can  appreciate  the  different  conditions 
that  occasion  compression  of  the  brain ;  but  we  still  speak  of  functional 
convulsive  disease  and  of  functional  amaurosis.  The  ophthalmoscope, 
however,  has  shown  that  “  functional”  amaurosis  does  not  exist,  but 
that  the  failure  of  visual  power  is  always  accompanied  by  and  dependent 
on  some  corresponding  change  of  structure  in  the  interior  of  the  ej^e ; 
and  advances  in  pathology  will  doubtless  show  that  other  so-called  func¬ 
tional  diseases  of  the  nervous  sj^stem  are  in  reality  dependent  on  struc¬ 
tural  lesions. 

State  of  the  Nerves  at  the  Seat  of  Injury. — There  is  one  morbid  con¬ 
dition  that  will,  I  think,  invariably  be  found  in  tetanus,  viz.,  a  marked 
congestion  and  inflammation  of  the  nerve  connected  with,  and  leading 
from,  the  wound  that  has  occasioned  the  disease.  This  morbid  state  I 
have  never  found  wanting.  In  all  cases  of  fatal  tetanus  that  I  have  seen 
in  which  a  careful  dissection  has  been  made,  the  signs  of  inflammation 
of  a  nerve  communicating  with  the  wound  have  been  found  ;  and  the 
vascularit}",  which  is  often  very  intense,  may  be  traced  up  the  neuri¬ 
lemma,  often  to  a  considerable  distance.  In  a  case  of  tetanus  following 
a  wound  of  the  knee,  in  a  patient  who  died  in  University  College  Hos¬ 
pital,  a  small  branch  of  the  internal  cutaneous  nerve  was  found  to  have 
been  injured,  and  was  inflamed.  In  another  patient  who  died  of  tetanus 
about  sixteen  days  after  treading  on  a  rusty  nail,  a  black  speck  was 
found  on  the  internal  plantar  nerve,  where  it  had  been  wounded  by  the 
nail.  In  a  man  who  died  of  acute  tetanus  a  week  after  receiving  a  lace¬ 
rated  wound  of  the  dorsum  of  the  foot,  the  digital  nerves  were  found 


TREATMENT  OF  TETANUS. 


751 


to  be  slough}',  and  evidences  of  inflammatory  irritation  extended  some 
distance  up  the  musculo-ciitaneous  nerve.  In  another  case  under  my 
care,  in  which  tetanus  resulted  from  a  bruise  of  the  back,  and  terminated 
in  death,  the  injured  nerve  (a  dorsal  branch)  was  found  lying  bare  and 
reddened  in  the  wound  ;  and,  on  tracing  it  up  to  the  spinal  cord,  its 
sheath  was  found  to  be  much  injured,  ecchymosed,  and  with  a  large 
vessel  running  down  it.  In  another  instance,  in  which  tetanus  followed 
a  wound  of  the  wrist,  the  external  cutaneous  nerve  was  found  in  a  simi¬ 
lar  inflamed  state. 

The  Pathological  Conditions  found  in  the  Spinal  Cord  in  cases  of 
tetanus  have  been  studied  by  Rokitansky,  Lockhart  Clarke,  Dickinson, 
and  Allbutt.  Rokitansky  described  them  as  consisting  chiefly  of  a  pro¬ 
liferous  development  of  connective  tissue,  composed  of  young  cells. 
Billroth  doubts  the  correctness  of  this  observation  ;  and  many  compe¬ 
tent  observers  have  failed  to  discover  anything  more  positive  than 
ecchymosed  patches  and  interspaces  in  the  spinal  medulla.  Lockhart 
Clarke  has  in  at  least  six  cases  observed  lesions  of  structure  in  the 
spinal  cord,  consisting  of  disintegration  and  softening  of  a  portion  of 
the  gray  substance  of  the  cord,  which  appeared  in  certain  parts  to  be  in 
a  state  of  solution.  The  fluid  thus  formed  was  in  some  parts  granular, 
holding  in  suspension  the  fragments  and  particles  of  the  disintegrated 
tissue,  but  in  many  places  it  was  perfectly  pellucid.  He  considers  this 
due  to  hypersemia  of  the  cord  accompanied  by  exudation  and  disintegra¬ 
tion.  Dickinson  has  described  intense  hyperoemia  with  a  structureless 
exudation  poured  out  around  the  vessels  in  many  parts  of  the  gray 
matter,  breaking  down  the  surrounding  tissue.  He  also  observed  some 
hemorrhages  in  the  white  columns.  These  observations  have  been  lately 
confirmed  by  Clifford  Allbutt,  who  found  in  four  cords  which  he  exam¬ 
ined  that  the  tissues  were  intensely  congested,  and  surrounded  by  spaces 
containing  a  structureless  exudation,  especially  in  the  gray  matter.  The 
absence  of  any  constant  and  distinct  pathological  lesion  has  led  to  the 
hypothesis  of  tetanus  being  dependent  primarily  on  blood-poisoning, 
and  not  on  a  lesion  of  the  nerve-centres.  Billroth,  who  inclines  to  this 
idea,  admits  that  it  is  a  mere  hypothesis.  This  theory  of  blood-poison¬ 
ing  being  the  primary  cause  of  tetanus  is  based  on  the  following  line  of 
argument.  A  septic  agent,  capable  of  producing  convulsive  movements 
when  absorbed  into  the  blood — of  acting,  in  fact,  like  strychnia — may  be 
supposed  to  be  generated  in  certain  circumstances,  whether  of  individual 
predisposition  or  of  epidemic  constitution,  in  the  wound  or  at  the  seat 
of  injury.  We  have  the  analogy  of  hydrophobia  in  support  of  the  idea 
that,  in  certain  circumstances,  such  an  agent  may  be  generated  in  the 
system,  rendering  the  fluids — blood  and  saliva — poisonous  to  others,  and 
capable  of  developing  a  convulsive  disease  in  the  animal  affected.  We 
have,  however,  no  evidence  as  yet  that  the  blood  or  any  one  of  the 
secretions  of  a  tetanic  patient  is  capable,  when  inoculated,  of  producing 
a  similar  disease  in  a  healthy  animal. 

There  is  one  objection  to  this  theory  w'hich  appears  to  me  too  serious 
to  be  overlooked:  viz.,  that  tetanus  has  been  arrested,  if  not  cured,  by 
the  division  of  the  principal  nervous  trunk  leading  from  the  seat  of 
injury,  as  the  posterior  tibial  nerve  in  cases  of  tetanus  arising  from 
wound  of  the  sole  of  the  foot.  This  fact  appears  to  me  to  point  rather 
to  a  primary  nervous  lesion  than  to  blood-poisoning  as  the  exciting  cause 
of  the  tetanic  convulsions. 

Treatment. — The  treatment  of  tetanus  is  of  a  local  and  of  a  consti¬ 
tutional  character.  The  Local  Treatment  has  for  its  object  the  removal 


752 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


of  the  irritation  that  has  induced  the  tetanic  condition.  It  is  true  that, 
when  once  tetanic  excitement  has  been  set  up  in  the  cord,  it  has  a  ten¬ 
dency  to  continue,  and  to  be  incapable  of  removal  by  the  mere  abstrac¬ 
tion  or  cessation  of  the  local  irritation,  which  gave  rise  to  it  in  the  first 
instance.  It  is,  however,  01113^  reasonable  to  suppose,  that  other  treat¬ 
ment  will  succeed  best  if  local  irritation  be  removed;  and,  indeed,  so 
long  as  this  continues  to  keep  up  the  centric  nervous  disturbance,  no 
general  means  can  be  expected  to  succeed ;  as  the3^  will  have  not  only 
to  combat  already  existing  disease,  but  also  to  overcome  the  continuous 
excitement  maintained  by  the  local  disturbance.  Hence,  it  is  of  use  to 
bring  the  wound  into  as  healthy  a  state  as  possible,  and  to  see  that  it  is 
clean,  free  from  foreign  bodies,  and  not  inflamed.  In  order  effectually 
to  remove  all  local  disturbance,  recourse  has  been  had  to  amputation ; 
but  though  this  ma3"  have  succeeded  in  checking  some  of  the  more  chronic 
forms  of  the  disease,  3"et  other  and  milder  local  means  have  sufficed 
equally  well,  and  in  the  majorit3"of  cases  it  has  had  no  effect,  and  hence 
so  severe  an  operation  can  scarcely  be  recommended  for  adoption.  The 
division  of  the  trunk  of  the  injured  nerve,  at  some  distance  above  the 
wound,  if  there  be  one  that  has  been  punctured  or  lacerated,  has  occa- 
sionall3'  proved  successful.  Thus,  in  a  case  of  tetanus  following  injury 
of  the  supraorbital  nerve,  Larre}'  cut  this  across,  and  the  patient  w^as 
cured.  In  a  midshipman,  in  whom  tetanus  came  on  the  da3'  after  the 
sole  of  the  foot  had  been  wounded  by  treading  on  a  rusty  nail,  Murray 
divided  the  posterior  tibial  nerve,  and  thus  cured  the  patient.  In  those 
cases  in  which  no  special  nerve  appears  to  have  been  injured,  Liston’s 
recommendation  of  making  a  /\ -shaped  incision  down  to  the  bone,  and 
above  the  part,  so  as  to  insulate  it  completely,  may  be  advantageously 
followed.  After  the  nerve  has  been  divided,  or  the  part  properH  insu¬ 
lated,  some  solution  of  atropine  may  be  carefully  applied  to  it,  so  as 
still  further  to  lessen  local  irritation. 

In  the  Constitutional  Treatment  of  the  disease,  it  is  necessary  to  bear 
in  mind  that  tetanus  is  an  affection  of  debility",  the  violence  of  the  spas¬ 
modic  paroxysms  giving  an  appearance  of  false  strength  to  the  patient: 
and  that  the  principal  source  of  danger  and  death  is  the  fatigue  and 
exhaustion  induced  by  the  energy  of  the  muscular  movements.  The 
means  adopted  should,  therefore,  have  for  their  object  the  removal  of 
irritation  and  the  support  of  the  patient’s  strength,  so  as  to  enable  him 
to  hold  up  against  the  disease. 

Nothing  can  be  more  unsatisfactory  than  the  treatment  of  the  Acute 
form  of  traumatic  tetanus.  In  it,  all  medicines  are  useless  as  curative 
agents.  But,  though  medicines  are  of  no  avail  as  means  of  cure,  they 
may  act  as  palliatives,  and  afford  relief  to  the  patient ;  and  much  may 
be  done  by  the  Surgeon,  by  removing  all  sources  of  external  irritation, 
to  mitigate  his  suferings,  and  to  place  him  in  a  favorable  condition  to 
withstand  the  exhaustion,  and  to  lessen  the  torture  of  the  spasm.  With 
this  view,  the  first  thing  to  be  done  is  to  clear  the  bowels  well  out  with 
an  aperient  dose ;  aided,  if  necessaiy,  b3^  a  turpentine  enema.  The 
patient  should  then  be  kept  perfectly  quiet  in  a  room  by  himself,  a 
screen  -or  muslin  curtains,  as  recommended  by  Marshall  Hall,  being 
drawn  around  the  bed,  as  noise  or  movement  of  any  kind  increases  the 
spasms  greatly.  In  order  to  allay  the  spinal  irritation,  the  most  effec¬ 
tual  means  consists  perhaps  in  the  plan  recommended  b}"  Todd,  of 
appl3dng  ice  along  the  whole  length  the  spine :  this  is  best  clone  b3"  one 
of  Chapman’s  spine-bags.  This  is  a  powerful  depressing  agent,  and, 
unless  care  be  taken,  may  lower  the  heart’s  action  too  much,  or  indeed 


TREATMENT  OF  TETANUS. 


753 


completely  extinguish  it.  It,  maj’’,  however,  be  applied  with  safety  for 
six  or  eight  hours,  the  condition  of  the  patient  being  looked  to  in  the 
meanwhile.  Sedative  or  antispasmodic  agents  are  of  no  use  whatever 
in  acute  traumatic  tetanus.  I  have  seen  many  drugs  of  this  kind  em¬ 
ployed  without  producing  any  effect  in  lessening  the  violence  of  the 
convulsions.  In  most  cases,  however,  the  inhalation  of  chloroform,  or 
the  administration  of  chloral,  materially  lessens  their  severity,  and  gives 
the  patient  at  least  temporary  ease. 

In  the  Subacute  or  Chronic  form  of  the  disease  recovery  is  much 
more  likel^^  to  take  place  ;  and  it  is  only  in  these  cases  that  antispas- 
modics  and  sedatives  have  been  of  use,  and  in  these  also  chloroform  and 
chloral  are  far  more  beneficial  than  in  the  acute  cases.  There  is  a  kind 
of  trismus  occurring  in  females,  often  of  a  h3’sterical  nature,  which  is  at 
once  removed  by  the  inhalation  of  chloroform.  Almost  every  drug  in 
the  pharmacopoeia,  of  tonic,  sedative,  or  antispasmodic  nature,  has  been 
emplo^-ed  in  these  cases ;  and  the  recoveiy  which  has  occasionally 
resulted  has  been  perhaps  overhastil^"  attributed  to  the  remedj’^,  rather 
than  to  the  employment  of  those  dietetic  and  hygienic  means,  which  are 
of  the  first  importance,  by  enabling  the  patient  to  live  on  until  the  dis¬ 
ease  wears  itself  out.  Tonics,  especially'  iron  and  quinine,  have  been 
employ'ed  by  some.  Elliotson  was  strongly  impressed  w’ith  the  value  of 
the  carbonate  of  iron.  Sedatives  in  all  forms — conium,  belladonna,  opium, 
and  their  alkaloids — have  been  largely'  and  most  ineffectually  employed. 
Miller  speaks  highly  of  cannabis  Indica  pushed  to  narcotism,  three 
grains  of  the  extract,  or  thirty'  minims  of  the  tincture,  being  given  every 
half  hour  or  hour ;  and  Haughton  has  employed  nicotine  in  one-drop 
doses,  administered  every  second  hour,  with  complete  success  in  severe 
cases  of  traumatic  tetanus. 

The  Calabar  bean  is  the  remedy  that  perhaps  deserves  physiologically 
the  most  attention  ;  for,  as  it  is  nearly'  if  not  quite  antagonistic  to  the 
tetanic  spasms  of  strychnia,  it  may  be  hoped  that  it  will  be  found  equally 
useful  as  a  sedative  to  the  spinal  cord  in  those  arising  from  traumatic 
causes.  In  E.  Watson’s  hands,  very  successful  results  have  followed  its 
administration.  Yet  it  is  far  from  being  a  specific.  I  have  tried  it  in 
several  cases,  with  no  appreciable  good  effect.  It  may  be  given  by'  the 
mouth,  hy'podermically',  or  per  anum  :  in  the  form  of  a  solution  or  a 
tincture  of  the  extract  in  half-grain  doses,  by  the  mouth ;  hypodermically, 
in  doses  of  one-sixth  of  a  grain ;  per  anum^  in  grain  doses.  The  dose 
should  be  given  at  least  every'  second  hour,  until  complete  contraction  of 
the  pupil  occurs.  Stimulants,  as  brandy',  should  at  the  same  time  be 
given  to  counteract  the  depression  that  will  result  from  the  use  of  the 
drug.  At  the  same  time  that  recourse  is  had  to  such  measures  as  these, 
it  must  not  be  forgotten  that  the  disease  is  one  of  great  exhaustion,  and 
that  the  patient  will  die  worn  out,  unless  he  be  supplied  with  plenty  of 
nourishment.  Beef-tea  and  wine  should,  therefore,  be  administered  by 
the  mouth,  as  long  as  the  patient  can  swallow,  and  nutritious  enemata 
by  the  rectum  ;  and  in  this  way  the  powers  of  life  may  be  supported  until 
the  violenee  of  the  disease  expends  itself  I  am,  however,  disposed  to 
think  that  even  in  these  chronic  cases  much  more  may  be  done  by  simple 
than  by'  specific  treatment.  Clearing  out  the  bowels  by'  a  turpentine 
enema,  breaking  the  violence  of  the  spasms  and  giving  the  patient  rest 
and  ease  by'  chloroform  inhalations  or  by  chloral  enemata,  and  keeping 
up  the  powers  of  the  system  by  injections  of  beef-tea,  egg,  and  brandy 
into  the  rectum,  till  the  disease  wears  itself  out,  appear  most  likely  to  be 
followed  by  a  satisfactory  result,  when  used  in  addition  to  the  hygienic 
VOL.  I. — 48 


754 


DISEASES  OF  LYMPHATICS  AXD  GLANDS. 


measures  recommended  in  the  acute  form  of  the  disease.  It  is  certainly 
more  rational  to  employ  such  measures  as  these,  than  to  be  constantly 
recurring  to  antispasmodics  and  sedatives,  which  repeated  experience  has 
proved  to  be  useless  as  curative  agents,  in  the  vain  hope  of  finding  a 
pecific  for  tetanus. 


CHAPTER  XXXIX. 

DISEASES  OF  THE  LYMPHATICS  AND  THEIR  GLANDS. 

INFLAMMATION  OF  THE  LYMPHATICS. 

Inflammation  of  the  Lymphatics^  Lymphatitis^  or  Angeioleucitis^  is  a 
diffuse  or  erysipelatous  inflammation  of  the  l3^mphatic  vessels.  In  it, 
according  to  Tessier,  the  13'mph  coagulates,  forming  a  ros3'  clot,  which 
obstructs  the  interior  of  the  vessel ;  the  w'alls  of  which,  at  the  same  time, 
become  thickened,  softened,  opaque,  and  surrounded  b3^  a  quantit3"  of 
infiltrated  areolar  tissue. 

Symptoms. — This  disease  may  be  idiopathic,  when  it  is  closel3"  asso¬ 
ciated  with  eiysipelas ;  but  more  commonl3’  it  is  set  up  from  the  irrita¬ 
tion  induced  133^  an  abrasion  or  wound.  During  the  progress  of  an  ordi- 
naiy  injury,  the  patient  is  seized  with  rigors,  followed  b3Hebrile  reaction, 
and  attended,  perhaps,  by  vomiting  or  diarrhoea.  These  S3^mptoms  often 
precede  *b3'  twelve  or  fourteen  hours  the  local  signs  of  the  disease,  but 
more  commonl3'  accompan3"  them.  On  examining  the  part  it  will,  if 
superficial,  be  seen  to  be  covered  b3"  a  multitude  of  fine  red  streaks,  at 
first  scattered,  but  graduall3’’ approximating  to  one  another  so  as  to  form 
a  distinct  band,  about  an  inch  in  breadth,  running  from  the  part  affected 
along  the  inside  of  the  limb  to  the  neighboring  13'mphatic  glands,  which 
may  be  felt  to  be  enlarged  and  tender.  The  band  itself  feels  somewhat 
dongh3’  and  thickened.  There  is  usually  more  or  less  oedema  of  the 
limb,  from  the  implication  of  the  deeper  la3'ers  of  vessels  and  their  ob¬ 
struction  b3'  the  inflammation.  Along  the  course  of  the  inflamed  absorb¬ 
ents,  eiysipelatous-looking  patches  not  unfrequentl3^  appear,  and  coalesce 
until  the3"  assume  a  considerable  size,  and  constitute  a  distinct  variet3’' 
as  it  were  of  eiysipelas.  In  some  cases  the  glands  are  affected  before 
an3"  other  local  signs  manifest  themselves,  owing  probabl3^  to  the  deeper 
seated  13’mphatics  having  been  first  implicated ;  and  not  uncommonly 
throughout  the  disease  the  inflammation  continues  to  be  confined  princi- 
pall3^  to  this  set  of  vessels,  giving  rise  to  great  and  brawn3^  sw'elling  of 
the  limb,  but  without  much  if  any  superficial  redness.  The  constitu¬ 
tional  disturbance,  at  first  of  the  active  inflammatoiy  type,  may  gradu¬ 
ally  subside  into  the  asthenic  form. 

Results. — The  disease  usuall3’  terminates  in  resolution  at  the  end  of 
eight  or  ten  da3’s  ;  not  uncommonl3’’  it  runs  on  to  eiysipelas  ;  and  in  other 
cases,  again,  limited  suppuration  ma3"take  place,  or  a  chain  of  abscesses 
ma3’  form  along  the  course  of  the  inflamed  absorbents  and  in  the  glands 
to  which  the3"  lead.  In  some  instances,  after  the  disajipearance  of  the 
disease,  a  state  of  chronic  and  rather  solid  oedema  of  the  part  may  be 
left,  giving  rise  indeed  to  a  species  of  false  h3'pertroph3q  and  constituting 
a  troublesome  consequence;  more  rarel3q  death  results  either  from  ery- 


INFLAMMATION  OF  LYMPHATIC  GLANDS. 


755 


sipelas,  from  pyaemia,  or  from  secondary  abscesses.  This  is  chiefly  in 
broken  constitutions,  in  which  the  disease  has  made  extensive  ravages, 
and  has  become  associated  with  low  cellulitis. 

Diagnosis. — The  diagnosis  of  inflammation  of  the  absorbents  is  easy  ; 
the  only  affections  with  which  it  can  be  confounded  being  erysipelas  and 
phlebitis.  From  erysipe/as  it  may  be  distinguished  by  the  streaked  cha¬ 
racter  and  limited  extent  of  the  redness  ;  though,  as  the  two  affections 
commonly  occur  together,  the  distinction  is  of  little  moment.  From 
phlebitis^  the  disease  may  be  distinguished  by  its  superficial  redness,  the 
inflammation  of  contiguous  glands,  and  the  absence  of  the  knotted  corded 
state  characteristic  of  an  inflamed  vein. 

Causes. — The  causes  of  inflammation  of  the  absorbents  closely 
resemble  those  of  eiysipelas ;  the  disease  being  ^specially  disposed  to 
b}''  atmospheric  vicissitudes,  by  particular  seasons  of  the  year,  more  espe¬ 
cially  the  early  spring,  and  by  the  epidemic  constitution  at  the  time 
tending  to  disease  of  a  low  type.  Broken  health  and  the  neglect  of 
hygienic  precautions  also  tend  to  induce  it.  Amongst  the  more  direct 
causes  are  wounds  of  all  kinds,  but  especially  such  as  are  poisoned  by  the 
introduction  of  putrid  animal  matters  or  other  irritants,  or  that  are  of 
recent  origin.  It  is  very  rarely  indeed  that  inflammation  of  the  absorb¬ 
ents  occurs  without  some  such  cause  ;  yet  I  think  we  are  warranted  in 
considering  it  as  of  idiopathic  origin  in  some  instances.  I  have  at  least 
seen  cases  in  which  careful  examination  has  failed  in  detecting  any  breach 
of  surface  or  evidence  of  poisonous  absorption. 

Treatment. — This  consists  in  the  eraplo3'ment  of  anti-inflammatory 
remedies,  such  as  the  application  of  leeches  along  the  course  of  the 
inflamed  absorbents,  followed  b}-'  assiduous  poppy  fomentations;  the 
limb  at  the  same  time  being  kept  elevated.  The  bowels  should  be  freely 
opened  ;  and  if  there  be  much  pj’rexia,  salines  with  antimony  may  be  ad¬ 
ministered.  If  the  fever  assume  rather  a  low  form,  the  liquor  ammonim 
acetatis  may  be  given  in  camphor  mixture ;  support  being  administered 
or  withheld,  in  accordance  with  the  principles  laid  down  when  speaking 
of  the  treatment  of  inflammation  generally.  If  chronic  induration  and 
oedema  occur,  the  application  of  blisters  will  be  found  to  be  of  use  in 
taking  down  the  swelling  and  hardness  ;  bandaging,  so  as  to  compress 
the  limb  methodicall}",  may  be  of  service  in  the  later  stages.  If  abscesses 
form,  these  should  be  opened  early,  and  treated  on  ordinary  principles. 

INFLAMMATION  OF  LYMPHATIC  GLANDS. 

Inflammation  of  the  Lymphatic  Glands^  or  Adenitis^  may  occur  either 
from  the  extension  of  inflammation  along  the  course  of  the  lymphatics 
from  the  irritation  induced  by  acrid  or  poisonous  substances  conve^^ed 
along  these  vessels,  and  not  inflaming  them,  but  inducing  diseased  action 
in  the  glands  through  which  they  are  carried ;  or  as  a  consequence  of 
strains  resulting  from  over-exertion,  as  is  often  seen  in  the  glands  of  the 
groin  from  walking  too  much.  In  whatever  way  occurring,  inflamma¬ 
tion  of  the  absorbent  glands  is  always  attended  by  a  stasis  of  the  l^^mph, 
with  coagulation  of  it ;  and,  if  the  whole  or  greater  part  of  the  glands  of 
a  limb  be  aflfected,  the  course  of  the  fluid  through  the  absorbent  vessels 
may  be  so  seriously  interfered  with,  that  oedema,  often  of  a  solid  char¬ 
acter,  occurs  in  the  lower  parts  from  which  the  l^^mph  ought  to  have 
been  conve^^ed. 

Varieties. — Adenitis  ma}^  be  acute,  subacute,  or  chronic.  In  Acute 
Adenitis^  which  almost  invariably  occurs  as  a  consequence  of  angeio- 


756 


DISEASES  OF  LYMPHATICS  AND  GLANDS. 


leucitis,  there  are  pain,  swelling,  tenderness,  and  stiffness  about  the 
affected  glands,  with  a  dull,  heav}*  sensation  in  them,  followed  by  all  the 
signs  of  acute  abscess,  the  glands  gradually  softening  in  the  centre,  and 
the  suppurative  inflammation  extending  to  the  contiguous  areolar  mem¬ 
brane,  through  which  it  becomes  somewhat  difiused.  Jn  Subacute 
Adenitis^  which  is  a  common  result  of  injuries  or  strains,  the  glands 
become  swollen,  enlarged,  and  tender,  and  are  matted  together  by  the 
inflammatory  and  plastic  consolidation  of  the  neighboring  tissues.  If 
abscess  form,  it  commonl}^  commences  in  the  structures  around  the 
glands ;  and  these  are  perhaps  eventually  exposed  at  the  bottom  of  the 
cavit}'  that  results.  This  is  especially  apt  to  happen  in  cachectic  and 
strumous  persons  from  slight  sources  of  irritation.  Very  commonlj^,  in 
such  subjects,  the  inflammation  of  the  glands  runs  into  a  Chronic  state; 
which,  indeed,  may  at  last  terminate  in  their  permanent  enlargement  and 
induration,  or  in  tuberculous  degeneration.  When  the  glands  become 
chronically  inflamed  from  the  first,  they  are  enlarged  and  hardened,  with 
tenderness -and  pain  about  them:  after  a  time  suppuration  takes  place 
within  them ;  or  perhaps  it  may  occur  in  the  areolar  tissue  around  them, 
which,  breaking  down,  leaves  them  in  the  form  of  reddish-gray  or  fleshy 
masses,  that  protrude  in  the  midst  of  the  suppurating  cavity :  as  the 
inflammation  subsides,  the  skin  becomes  of  a  reddish-blue  or  purple  hue, 
is  thinned,  and  firml}^  incorporated  with  the  subjacent  tissues. 

Strumous  Enlargement  of  Glands. — The  glands  not  uncommonly 
enlarge  chronically  without  inflammation,  simplj'  as  the  result  of  stru¬ 
mous  disease  or  of  chronic  irritation  of  some  kind.  They  may  remain 
permanently  enlarged,  or,  after  continuing  so  for  months  or  years,  may 
slowly  break  down  into  unhealthy  suppuration,  leaving  the  skin  thin, 
blue,  and  undermined,  with  weak  and  often  protuberant  cicatrices.  The 
pus  is  curdy  and  ill-conditioned.  In  all  probability,  the  peculiar  enlarge¬ 
ment  and  tendency  to  unhealthy  suppuration  arise  from  the  deposit  of 
tuberculous  matter  within  the  gland.  These  changes  principal!}"  occur 
in  the  neck,  especiall}'  in  the  submaxillary  glands  and  the  glandulse  con¬ 
catenate,  sometimes  in  the  axillaiy  or  inguinal  glands,  forming  large 
indurated  and  nodulated  tumors  matted  together,  and  suppurating  in 
the  interstices  of  the  areolar  tissue,  or  in  the  substance  of  the  glands 
themselves.  This  strumous  enlargement  of  the  glands  occurs  chiefly  in 
children  and  in  young  people ;  in  whom,  indeed,  it  is  commonly  looked 
upon  as  one  of  the  most  frequent  accompaniments  of  the  strumous  diath¬ 
esis. 

Treatment. — The  treatment  of  inflamed  absorbent  glands  varies 
greatly,  according  to  the  stage  of  the  affection.  In  the  acute  stage, 
leeches  and  fomentations  are  especiall}^  required.  In  the  subacute  con¬ 
dition,  spirit-lotions  containing  the  iodide  of  potassium  will  subdue  the 
inflammation  and  take  down  the  swelling  ;  at  the  same  time,  the  health 
must  be  regulated  by  aperients,  and  a  moderate  anti-inflammatoiy  plan 
of  treatment.  If  abscess  form,  it  must  be  opened  with  a  knife,  and  the 
part  well  poulticed  afterwards  ;  the  fistulous  openings,  which  are  often 
left,  require  to  be  treated  by  stimulating  applications,  especially  the 
nitrate  of  silver,  but  very  commonl}"  they  will  not  heal  unless  they  are 
slit  up  and  dressed  from  the  bottom. 

Chronic  inflammation  with  lypertroph}^  of  the  lymphatic  glands,  or 
the  induration  left  as  the  result  of  the  acute  disease,  requires  to  be 
treated  on  different  principles.  If  there  be  any  pain  and  tenderness  about 
the  glands,  the  application  of  the  iodide  of  potassium  and  spirit-lotion 
will  be  required.  If  the}"  have  already  suppurated,  and  an  aperture  exist 


LYMPHADENOMA. 


757 


leading  down  to  an  indurated  mass,  or  if  there  be  surrounding  indura¬ 
tion  of  the  soft  tissues,  it  is  often  a  good  plan  to  rub  the  ulcerated  part 
freely  with  caustic  potass,  which  will  dissolve  it  away  bj^  exciting  inflam¬ 
mation  around  the  plastic  deposit,  and  thus  causing  its  dissolution  into 
pus.  When  there  is  merely  chronic  enlargement,  without  irritation, 
methodical  friction  with  iodine  or  iodide  of  lead  ointment  will  produce 
absorption  of  the  inflammatory  effusion  constituting  the  bulk  of  the 
enlargement ;  and  this  in  many  instances  may  remove  the  tumor  entirely. 
In  other  cases,  painting  the  part  with  the  tincture  of  iodine,  and  improve¬ 
ment  of  the  general  health,  will  cause  the  removal  of  the  diseased  struc¬ 
ture.  After  abscess  has  formed  and  been  opened,  flstulous  openings  will 
be  left,  into  which  large  masses  of  hypertrophied  gland  may  be  seen  to 
project.  These  are  best  reduced  by  the  red  oxide  of  mercury,  or  potassa 
fusa;  indeed,  if  the  glands  be  much  enlarged  and  indurated,  projecting 
into  the  openings  made  over  them,  the  potassa  fusa  is  the  best  applica¬ 
tion  that  can  be  made  use  of,  breaking  down  and  dissolving  away  the 
indurated  mass.  In  applying  it,  care  must  be  taken  that  the  caustic  do 
not  spread  too  widely;  this  may  usually  be  avoided  by  coating  the  sur¬ 
rounding  integuments  with  collodion.  Extirpation  of  enlarged  lymph¬ 
atic  glands  is  seldom  necessaiy,  and,  if  undertaken,  may  lead  to  more 
serious  and  extensive  dissections  than  might  appear  at  first  requisite ; 
for  a  chain  of  diseased  glands  often  extends  to  a  considerable  distance, 
and  after  one  has  been  removed,  others  come  into  sight.  As  a  general 
rule,  this  operation  should  not  be  undertaken  :  cases,  however,  occasion¬ 
ally  occur,  in  which  such  a  procedure  may  be  deemed  advisable,  the 
affected  glands  being  large,  indurated,  and  tuberculous,  and  their  disease 
of  man}"  3'ears’  standing;  their  extirpation  may  then  be  proper,  and  I 
have  not  unfrequently  had  occasion  in  such  circumstances  to  remove 
them  from  the  axilla,  from  the  submaxillary  region,  and  from  the  pos¬ 
terior  triangle  of  the  neck. 

The  lymphatic  glands  occasion  all}’’  become  much  enlarged  in  the  neck, 
axilla,  and  groin  without  any  indications  of  struma,  but  attended  by 
much  debility, and  usually  great  emaciation;  in  these  circumstances,  the 
best  remedies  are  liquor  potassse  in  full  doses,  iodide  of  iron,  and  cod- 
liver  oil. 

OTHER  DISEASES  OF  LYMPHATICS  AND  THEIR  GLANDS. 

Lymphadenoma,  or,  as  it  is  also  called,  Simple  Lymphoma^  is  a 
tumor  composed  of  a  tissue  exactly  resembling  the  cortical  part  of  a 
lymphatic  gland — the  so-called  “  adenoid  tissue  of  His.”  It  usually 
grows  from  pre-existing  lymphatic  tissue,  and  the  situations  in  which 
it  most  commonly  comes  under  the  observation  of  the  Surgeon  are 
in  connection  with  the  lymphatic  glands  of  the  neck,  axilla,  or  groin. 
These  tumors  are  also  not  uncommonly  found  in  the  upper  part  of  the 
pharynx,  growing  from  the  lymphatic  follicles  in  that  region.  They  may 
be  single,  and  then  usually  of  a  general  size  ;  but  they  may  affect  all  the 
lymphatic  glands,  the  liver,  spleen,  kidneys,  etc.,  at  the  same  time.  This 
condition  may  be  accompanied  by  an  excess  of  white  corpuscles  in  the 
blood,  constituting  the  disease  known  as  leucocythiemia ;  or  this  symp¬ 
tom  may  be  absent,  constituting  the  disease  described  by  Trousseau  under 
the  name  of  Adenie.  The  enlargement  is  not  accompanied!  by  pain  or 
inflammation. 

These  tumors  may  vary  in  size  from  a  millet-seed  to  a  foetal  head. 
Several  such  tumors  may  unite  together,  forming  a  single  mass ;  if 


758 


DISEASES  OF  LYMPHATICS  AND  GLANDS. 


situated  in  the  neck  or  in  connection  with  the  bronchial  glands,  it  may 
cause  death  b}^  pressure  on  the  trachea.  They  are  usually  tolerably  well 
defined;  but  they  are  described  by  Billroth  as  occasionally  invading  the 
surrounding  tissue,  then  forming  the  so-called  malignant  lymphomata. 
Such  cases  are  alwa3's  fatal  bj.’  marasmus  and  anaemia.  Billroth  describes 
U^mphoma  as  occurring  also  in  tissues  not  belonging  to  the  Ij^mphatic 
system,  as  in  the  jaw,  scapula,  areolar  tissue,  etc. 

In  the  lymphatic  glands, l^^mphadenoma  resembles  simple  h3''pertrophy; 
but  on  section  it  will  be  found  that  all  distinction  between  cortical  and 
medullary  parts  is  lost,  the  whole  mass  being  composed  of  tissue  resem¬ 
bling  the  cortical  part.  On  section,  l^'mphadenoma  much  resembles 
medullaiy  cancer;  it  is  soft,  grayish  in  color,  with  spots  of  red,  due  to 
hemorrhages  or  dilated  vessels ;  and  opaque  or  chees}^  spots  may  be 
scattered  through  it.  It  yields  a  juice  on  scraping,  like  cancer-juice. 
The  juice  obtained  by  scraping  a  lymphadenoma  is  found,  with  the  aid 
of  the  microscope,  to  be  composed  of  innumerable  round  cells,  having 
the  size  and  appearance  of  lymph-corpuscles  or  the  white  corpuscles  of 
the  blood.  On  examining  the  tumor  by  means  of  sections  made  from 
hardened  specimens,  a  delicate  reticulate  stroma  is  seen,  the  meshes  of 
which  are  filled  with  the  cells  found  in  the  juice  above  mentioned.  The 
stroma  can  only  be  seen  clearly  b}^  washing  out  the  cells,  either  by 
shaking  the  section  in  water  or  brushing  it  with  a  camel’s-hair  pencil. 

The  Diagnosis  of  these  tumors,  when  in  the  l^^mphatic  glands,  from 
chronically’  inflamed  glands,  is  impossible  in  the  early  stages.  It  is 
only  when  their  power  of  continuous  growth  becomes  apparent  that  we 
call  them  ly’mph adenomata. 

Such  tumors  have  often  been  successfully  removed  from  the  axilla. 
One  which  was  as  large  as  a  fist,  was  lately  removed,  in  University 
College  Hospital,  from  the  axilla.  The  patient,  a  delicate  woman,  had 
a  group  of  similar  growths  in  the  neck,  which  had  remained  stationary'’ 
for  twenty  y’ears. 

Elephantiasis  of  the  Legs  and  Scrotum. — Elephantiasis  Arabum, 
or,  as  it  is  often  called,  the  Barhadoes  Leg^  is  an  affection  that  is  com¬ 
mon  in  many?-  tropical  countries,  in  the  West  Indian  Islands  and  in  South 
America  more  particularly.  It  is  met  with,  though  comparatively’’  rarely, 
in  Europe.  The  disease  usually  affects  one  of  the  lower  extremities 
(seldom  both),  the  scrotum,  or  the  labia,  w’hich  may  become  enormously 
enlarged  and  hypertrophied.  In  the  face  it  is  often  met  with  ;  in  the 
upper  extremities  rarely\ 

It  is  not  my  intention  to  enter  into  an  account  of  the  history^,  the 
symptoms,  or  causes  of  this  remarkable  malady’.  It  is  sufficient  for  my 
purpose  here  to  say’,  that  it  appears  to  consist  in  disease  primarily 
seated  in  the  lymphatics  The  glands,  as  Virchow  and  Rindfleisch  sup¬ 
pose,  become  impervious  to  the  transmission  of  ly’mph,  and  the  hy^po- 
plastic  deposits  that  characterize  the  disease  are  the  consequence,  together 
with  the  general  stretching  and  hyqDertrophy  of  the  integumental  struc¬ 
ture,  of  the  plastic  effusion  into  the  areolar  tissue. 

Treatment. — When  this  disease  attacks  the  face,  little,  if  anything, 
avails  in  the  way  of  treatment.  When  it  affects  the  labia  and  scrotum, 
the  enlarged  and  diseased  part  must  be  removed.  But  when  the  leg  is 
affected,  surgery  can  effect  much  in  the  way  of  cure.  In  the  slighter 
cases  much  may^be  done  by  elevation  of  the  limb,  methodical  bandaging^ 
and  perhaps,  as  Rayer  and  Lisfranc  recommend,  the  employ^ment  of  sca¬ 
rification.  But  in  the  more  severe  cases,  where  the  limb  has  swollen  to 
a  monstrous  size,  and  has  become  shapeless  from  the  groin  to  the  ankle. 


ELEPHANTIASIS. 


759 


the  skin  sallow,  covered  with  nodules  and  overlaid  by  a  branii}^  desqua¬ 
mation,  with  a  tendency  to  unhealthy  and  incurable  ulcerations — in  these 
advanced  and  serious  cases  more  active  measures  are  necessary. 

Dufour  seems  to  have  been  the  first  to  propose  diminution  of  the  sup¬ 
ply  of  arterial  blood  to  the  limbs  as  a  cure  for  this  disease.  This  he 
efifected  by  compressing  the  femoral  artery  by  means  of  a  kind  of  truss, 
and  was  successful  in  four  cases.  This  practice  of  compression  has  since 
been  successfully  followed  by  Hill,  Cockle,  Yanzetti,  and  others. 

TABLE  I. 


Table  of  Ligature  of  Femoral  Artery  for  Elephantiasis. 


Surgeon. 

Sex.  Age. 

Seat  and  Duration  of  Disease. 

I  Results. 

1.  Carnochan  . 

M.  27 

Right  lower  limb.  6  months  . 

Cure  permanent. 

2. 

M.  30 

Left  leg.  6  years;  many  ulcer¬ 
ations  . 

Relapse  after  14  mos. 

3. 

F.  25 

Right  lower  limb.  5  years 

Cure. 

4.  “ 

F.  26 

Both  lower  limbs.  5  years 

Right  femoral  tied  in 
Jan.  ;  left  in  April, 
1858.  Great  im¬ 
provement  in  both 
limbs. 

5.  Ogier.  .  . 

M.  26 

Leg  and  foot.  Several  years  . 

Cure. 

6.  Butcher  .  . 

F.  44 

Right  leg.  18  years  .... 

Operation  verj’’  diffi¬ 
cult.  Cure  after  41- 
years. 

7.  Richard  .  . 

F.  28 

Left  lower  limb.  13  years  .  . 

Cure. 

8.  Fayrer  .  . 

9.  “ 

M.  30 

Right  leg.  7  years  .... 

Right  leg . 

Death  from  pyaemia 
on  18th  day. 

Death. 

10.  Alcock  .  . 

M. 

Leg  ulcerated.  2  years .  .  . 

Improvement. 

11.  H.  Watson  . 

M. 

Leg . 

Improved. 

12.  Yanzetti .  . 

F.  21 

Right  lower  limb.  7  years  .  . 

Cured  after  3  years. 

13.  T.  Simpson . 

F.  41 

Left  lower  limb.  31  years  .  . 

Cured  after  3  months. 

14.  Baum  .  . 

M.  31 

Left  lower  limb.  13  years  .  . 

No  benefit. 

15.  “  .  . 

F.  38 

Left  leg.  33  years  .... 

Gangrene — Death. 

TABLE  II. 


Ligature  of  the  External  Iliac  for  Elephantiasis. 


Surgeon. 

Sex.  Age. 

Situation  and  Duration  of  Disease. 

Result*. 

1.  T.  Bryant 

F. 

25 

Left  lower  limb.  10  years  after 
scarlatina . 

Cure  after  7  months. 

2.  G.  Buchanan 

F. 

17 

Left  lower  limb.  5  years  .  . 

Temporary  improve¬ 
ment.  Relapse  af¬ 
ter  11  months. 

3.  C.  Hufter 

F. 

23 

Left  lower  limb.  8  years  .  . 

Cure. 

4.  Simon  .  .  . 

F. 

20 

Left  lower  limb.  4  years. 
Right  limb  slightly  affected. 

1  year . 

Left  external  iliac  tied. 
Temporary  benefit. 
Relapse  in  8  mos. 

I 


DISEASES  OF  LYMPHATICS  AND  GLANDS. 


7t)0 


TABLE  III. 


Ligature  of  other  Arteries  for  Elephantiasis. 


Surgeon. 

Sex.  .\ge. 

Situation  and  Duration  of  Disease. 

Results. 

1.  Statliam  .  . 

M.  42 

Foot  and  ankle . 

Anterior  tibial  tied  in 
middle  third  of  leg. 
Improvement. 

2.  Carnochan  . 

F.  42 

Elephantiasis  Grseconim.  Face 
enormously  swollen  .  .  . 

Right  common  carotid 
tied.  AfterGmos., 
left  common  carotid 
tied.  Some  nodules 
removed.  Cure  af¬ 
ter  8  years. 

To  Carnochan  is  due  the  merit  of  bavin sj  recommended  the  lio^ature  of 
the  femoral  artery  as  a  means  of  cure  in  these  cases  ;  and,  in  whatever 
way  it  acts,  there  can  be  no  doubt  of  the  excellent  effects  that  have  fol¬ 
lowed  this  method  of  treatment,  little  as  it  can  be  explained  by  the 
received  pathological  views  of  the  disease.  In  some  instances,  as  by 
Bryant,  Buchanan,  and  Simon  (of  Heidelberg),  the  external  iliac  has  been 
advantageously  tied.  The  operation  on  this  artery  has  the  recommenda¬ 
tion  not  only  of  being  completelj’’  above  the  limits  of  the  disease,  and 
consequently  in  parts  that  are  quite  healthy,  but  also  of  more  completely 
controlling  the  nutrition  of  the  limb  than  can  be  done  by  ligature  of  the 
superficial  femoral. 

The  result  of  the  operation  appears  to  have  been  fairly  encouraging  in 
a  certain  number  of  cases,  though  in  a  large  proportion  it  is  evident,  by 
the  above  Tables,  that  little  if  any  improvement  took  place.  Much 
doubtless  depends  on  the  real  nature  of  the  disease — whether  true  ele¬ 
phantiasis  or  simple  enlargement  of  the  limb  from  the  deposit  of  lowly 
organized  plastic  deposit  of  a  less  specific  character.  The  latter  proba¬ 
bly  undergoes  absorption,  when  the  nutritive  supply  of  blood  has  been 
cut  off,  much  more  readily  than  the  former. 

Varix  of  the  Lymphatics  has  been  occasionally  met  with,  both  in 
the  superficial  and  deep  networks  and  in  the  lymphatic  trunks.  The 
part  most  commonly  found  affected  has  been  the  inner  side  of  the  thigh  ; 
but  the  disease  has  also  been  seen  in  the  anterior  wall  of  the  abdomen, 
about  the  ankle  and  elbow-joints,  and  on  the  prepuce.  In  the  superficial 
lymphatics,  the  varix  first  appears  in  the  form  of  small  elevations,  giving 
the  skin  an  appearance  which  has  been  compared  to  the  rind  of  an 
orange ;  it  subsequently  takes  the  form  of  little  vesicles  covered  with  a 
thin  la3’er  of  epidermis.  Yarix  of  the  larger  l3'mphatic  trunks  frequently 
accompanies  the  condition  just  described.  The  vessel  ma3^  either  be 
dilated  C3Tindricall3"  into  round  beaded  enlargements,  often  semi-trans¬ 
parent,  and  but  slightly  compressible ;  or  ampullae  may  be  formed  on 
them,  giving  rise  to  more  or  less  soft  swellings,  fluctuating  under  the 
finger.  There  is  some  oedema,  attributable  either  to  obstruction  of  the 
l3^mphatics  or  to  the  impeded  flow  of  the  l3unph. 

In  31  out  of  55  recorded  cases,  a  discharge  of  l3unph  {Lymph orrhcea) 
has  been  observed.  This  has  also  been  seen  to  occur  without  varix, 
as  the  result  of  wound.  In  the  latter  case,  the  flow  is  continuous; 
while  in  the  lymphorrhoea  which  attends  varix,  it  is  to  some  extent 
intermittent.  The  identit3’  of  the  fluid  discharged  -with  l3"mph  has  been 
established  b3^  chemical  and  microscopic  examination.  An  excessive 


PHLEBITIS. 


761 


discharge  of  the  fluid  is  liable  to  produce  symptoms  of  general  debility, 
of  the  same  kind  as  those  induced  by  hemorrhage. 

Treatment, — Spontaneous  cure  of  13'mphatic  varix  has  been  observed 
in  cases  where  the  penis  was  affected,  the  disease  being  the  result  of  the 
obstruction  to  the  flow  of  13'mph  caused  b3’'  buboes.  In  other  instances, 
various  plans  of  treatment  have  been  tried,  with  apparently  indifferent 
result.  Caustics  have  been  used  b3’'  several  Surgeons,  but,  as  the  disease 
is  often  deeply  seated  as  well  as  superficial,  with  but  little  result.  Beau 
treated  three  cases  successfull3"  b3"  introducing  a  seton  into  the  dilated 
l3’'mphatic  vessels,  and  exciting  adhesive  inflammation.  B.  Bell  advises 
ligature  of  the  13’mphatic  vessel  from  which  the  discharge  of  fluid  takes 
place.  Compression  1)3^  means  of  a  bandage  has  been  recommended  b3’’ 
Xelaton. 

Besides  the  diseases  of  the  l3"mphatics  and  those  glands  here  described, 
other  pathological  conditions  have  been  observed.  Thus,  the  glands 
may  undergo  cancerous  degeneration  as  the  result  of  absorption  from  a 
primaiy  cancer;  and  in  other  cases  the3^  have  been  found  to  have  under¬ 
gone  calcification  as  the  result  of  tuberculous  degeneration. 


CHAPTER  XL. 

DISEASES  OF  A’EIIIS, 

PHLEBITIS. 

In  flammation  of  the  Veins,,  original^*  studied  bv  Hunter,  has  in  later 
3’'ears  attracted  the  attention  of  man3^  distinguished  Continental  and 
British  pathologists,  amongst  whom  ma3"  be  especialH  mentioned  Bres- 
chet,  Velpeau,  Cruveilhier,  Arnott,  Henry  Lee,  and  Tessier. 

Phlebitis  is  of  two  kinds.  Idiopathic  and  Traumatic.  Idiopathic 
phlebitis  will  occur,  indepeudentL’  of  aiw  external  exciting  cause,  or 
perhaps  from  exposure  to  wet  and  cold,  in  one  of  the  large  veins,  almost 
invariabl3'  those  of  the  lower  extremit3’ — the  saphena,  popliteal,  femoral, 
or  iliac.  It  most  usualL’’  assumes  the  adhesive  form;  and  is  most  com- 
monl3"  met  with  in  persons  of  gout3’  constitution. 

Traumatic  phlebitis  is  commonly  excited  by  the  wound  of  veins,  as  in 
operations,  venesection,  and  injuries  of  various  kinds;  or  it  ma3’'  result 
from  their  contusion,  or  the  application  of  ligatures  to  them,  and  it  is 
especiall3"  predisposed  to  b3'  a  previousl3"  healthy  condition  of  the  blood, 
by  epidemic  constitution,  and  b3’’  season — in  fact,  b3^  those  influences 
that  dispose  generally  to  the  low  and  diffused  forms  of  inflammation. 
It  is  sometimes  adhesive,  but  not  unfrequentL"  diffuse,  and  is  highly 
dangerous,  being  often  the  forerunner  and  the  exciting  cause  of  p3’8emia. 
To  this  variet3^  of  phlebitis  ma3^  be  referred  the  ordinary  phlegmasia 
dolens  and  white  leg  of  parturient  women. 

Pathology. — When  a  vein  is  inflamed,  important  changes  occur  both 
in  the  coats  of  the  vessel  and  in  the  contained  blood.  The  coats  gene- 
rall3’  become  thickened,  the  outer  one  especial^’  being  vascular  and  infil¬ 
trated;  the  inner  coat  becomes  softened,  pulp3^,  and  usuall3^  more  or  less 
stained  of  a  dark  red  or  purple  hue  by  the  coloring  matter  of  the  blood. 
The  blood  in  the  inflamed  vessel  coagulates,  and  adheres  to  its  sides  ; 


762 


DISEASES  OF  VEINS. 


this  tendency  to  coagulation  and  adhesion  being  increased  by  the  effu¬ 
sion  of  lymph  from  the  wall  of  the  vessel.  This  plugging  of  the  vein 
appears  to  be  due  to  two  distinct  causes,  which  may,  however,  be  asso¬ 
ciated — one  being  inflammator3",  the  other  embolic. 

When  a  vein  has  become  primarily  inflamed,  a  thin  membranous  layer 
of  lymph  is  deposited  upon  its  interior,  closelj"  attached  to  the  lining 
membrane  of  the  vessel ;  this  thin  expansion  of  exudative  lymph  attracts 
the  fibrine  of  the  passing  blood,  which  thus  tends  to  become  deposited 
on  and  to  be  incorporated  with  it.  The  mass  grows  by  a  process  of 
aggregation  until  the  whole  of  the  vessel  is  filled  for  a  distance  of  one, 
two,  or  more  inches  by  this  plug  or  thrombus — partly  composed  of 
exudative  material,  partly  of  coagulated  blood. 

But  there  is  another  form  of  the  disease,  the  Embolic^  in  which  the 
vein  becomes  plugged  in  a  different  manner.  In  these  cases,  blood 
charged  with  minute  granular  embola,  the  result,  possibly,  of  the  disinte¬ 
gration  of  arterial  thrombi  (p.  616),  circulates  through  the  body,  and 
passing  through  the  capillaries  arrives  at  last  at  some  position  in  the 
venous  system  where,  favored  by  anatomical  arrangement,  previous 
disease  of  the  coats  of  the  vessel,  or  accidental  constriction  from  position 
of  a  limb  or  part,  the  embolon  separates  itself  from  the  circulating  blood 
and  becomes  deposited  on  the  inner  surface  of  the  vein,  where  it,  in  its 
turn,  forms  the  nucleus  of  a  thrombus,  by  which  the  vessel  is  speedily 
plugged.  This  thrombus  may  become  broken  up  and  disintegrated. 
Embola  may  become  detached  from  it,  and,  passing  up  to  the  right  ven¬ 
tricle,  may  be  driven  into  the  pulmonary  artery  b}^  the  cardiac  contrac¬ 
tions,  and,  according  as  the}- obstruct  its  larger  or  its  smaller  divisions, 
mav  be  the  cause  of  sudden  death  or  of  some  of  those  forms  of  intra- 
pulmonic  hemorrhage  that  usuallj^  go  b}^  the  name  of  “  pulmonary  apo¬ 
plexy.”  Thus  embola  formed  in  and  starting  from  the  left  cavities  of 
the  heart,  becoming  disintegrated,  may  pass  through  the  capillaries  into 
the  veins,  there  to  be  deposited,  forming  thrombi  which,  in  their  turn 
breaking  up,  yield  fresh  embola  that  may  be  productive  of  fatal  plugging 
of  the  pulmonary  arteiy,  the  plug  making  the  whole  of  the  circuit  of  the 
vascular  sj’stem  before  it  becomes  destructive  of  life.  These  changes 
may  occur  in  au\'  vein,  external  or  internal,  and  we  often  find  them 
associated — the  same  vessel  containing  a  mixture  of  coagulum  and 
fibrine.  The  extent  of  surface  which  the  inflammation  may  occupy  varies 
from  that  of  a  small  vessel  a  few  inches  in  length,  to  the  trunk  and 
branches  of  one  of  the  largest  veins  in  the  bod}^  The  obstruction  of 
the  vein,  which  is  the  common  result  of  these  forms  of  the  disease,  may 
continue  permanently  ;  the  plug  becoming  incorporated  with  its  coats, 
and  gradually  undergoing  fibro-cellular  degeneration,  so  that  the  vein  is 
converted  into  an  impervious  cord.  In  other  cases,  a  channel  eventually 
forms  through  the  axis  of  this  obstructing  clot,  allowing  the  circulation 
through  the  vein  to  be  re-established  in  a  more  or  less  imperfect  manner. 

Symptoms _ In  phlebitis  the  action  is  usually  localized,  and  limited. 

Commonly  the  disease  is  idiopathic,  but  it  may  arise  from  traumatic 
causes,  and  not  unfrequently  is  subacute.  When  traumatic,  it  may  occur 
in  an}^  vein  that  is  wounded  ;  but,  when  idiopathic,  it  commonly  occurs 
in  those  situated  in  the  calf  or  leg,  especially  if  they  be  varicose.  The 
inflamed  vein  becomes  hard,  swollen,  knoljioed,  and  painful,  the  knobs  con¬ 
stituting  distinct  enlargements  opposite  to  the  valves ;  if  superficial,  it 
presents  a  reddish-purple  color ;  and  there  is  some  degree  of  pain,  stiffness, 
or  inabilit}’’  to  move  the  limb.  There  may  perhaps  be  no  pain  when  the 
limb  is  at  rest,  but  in  some  cases  there  are  very  severe  shocks  of  pain, 


DIFFUSE  PHLEBITIS. 


763 


resembling  neuralgia,  darting  through  the  limb  ;  and  in  all  cases  there 
is  deep  tenderness  over  the  course  of  the  vessel.  There  is  always  some 
oedema  around  the  inflamed  vein,  and  in  the  part  that  supplies  it  with 
blood.  This  oedematous  condition  of  the  limb  is  a  most  important  diag¬ 
nostic  sign  in  deep-seated  embolic  phlebitis  when  the  vein  cannot  be  felt 
(as  in  the  pelvis,  for  instance),  and  may  perhaps  be  the  first  s^unptom 
observed,  coming  on  either  suddenly  or  gradually.  The  oedema  may 
give  rise  to  a  hard,  white,  and  tense  condition  of  the  limb,  which  pits 
on  pressure,  though  in  some  cases  the  hardness  is  too  great  for  this. 
Occasionally,  in  deep  phlebitis,  the  limb  may  suddenly  swell  to  a  con¬ 
siderable  size  without  there  being  any  subcutaneous  oedema.  In  phlebitis 
of  the  deep  veins  of  the  leg  and  thigh,  the  calf  of  the  affected  limb  may 
suddenly  enlarge,  with  great  pain  and  much  distension  of  the  superficial 
veins  with  fiuid  blood,  but  without  any  subcutaneous  oedema.  As  the 
inflammation  subsides,  the  swelling  of  the  limb  goes  down,  the  circula¬ 
tion  passing  through  its  former  channels,  or  the  blood  being  carried  off 
by  the  collateral  venous  system.  If  suppuration  occur,  no  change  takes 
place  in  the  S3^mptoms  so  long  as  the  pus  is  localized  or  encysted.  It 
ma3'  perforate  the  coats  of  the  vein,  and,  passing  into  the  external 
areolar  tissue,  form  a  common  abscess.  If  it  break  through  its  plastic 
barriers  within  the  vein,  then  a  very  difierent  result  occurs,  and  the 
symptoms  of  pyaemia  come  on.  But,  unless  this  occur,  the  constitutional 
disturbance  in  this  form  of  phlebitis  is  veiy  mild. 

The  Treatment  of  phlebitis  consists  in  absolute  rest  of  the  limb,  and 
hot  fomentations ;  at  the  same  time  salines  and  purgatives  must  be 
administered,  and  recourse  be  had  to  the  ordinary  anti-inflammatory 
means.  If  depression  come  on,  carbonate  of  ammonia  must  be  earl3’’ 
given.  The  hardness  which  is  often  left  after  the  removal  of  the  inflam¬ 
mation  ina3'’  usually  be  removed  b3"  salt  and  nitre  poultices,  as  recom¬ 
mended  by  Basham.  If  abscesses  form,  they  must  be  opened.  If  oedema 
of  the  limb  continue,  the  application  of  blisters,  or  the  pressure  of  an 
elastic  roller,  will  remove  it.  But  the  limb  rarel3’,  if  ever,  completely 
recovers  its  natural  size. 

Diflfuse  Phlebitis  is  an  eiysipelatous  form  of  the  disease,  often 
runninq;  for  a  considerable  distance  alonq^  the  linins:  membrane  of  the 
vein,  which  becomes  thickened,  pulp3’-,  and  red,  without  adhesions 
forming  or  the  blood  coagulating ;  indeed,  in  cases  of  this  kind  there 
appears  to  be  a  great  want  of  plasticity  in  that  fluid.  This  form  of 
phlebitis  is  commonl3’',  though  not  alwa3^s,  fatal:  its  fatality  was  sup¬ 
posed  b3’’  Hunter  to  be  owing  to  the  extension  of  the  inflammation  to 
tlie  heart,  and  b3’’  Hodgson  to  the  extent  of  surface  affected  ;  but  Arnott 
has  show'll  that  the  inflammation  scarcely  ever  reaches  the  heart,  and 
that  the  extent  of  vein  inflamed  is  commonly  very  limited — it  not  unfre- 
quently  happening  that  the  disease  proves  fatal  w’hen  but  a  few  inches 
are  affected,  as  in  the  vessels  of  a  stump.  Hence  it  is  probable  that 
death  is  owing  either  to  the  admixture  of  pus  with  the  blood  that  circu¬ 
lates  through  the  inflamed  portion  of  the  vein,  or  to  such  changes, 
induced  in  the  blood  by  the  inflamed  surface  over  which  it  passes,  as  are 
incompatible  with  life. 

Symptoms. — The  diffuse  phlebitis  is  ushered  in  by  the  ordinary  symp¬ 
toms  of  pyrexia,  at  the  same  time  that  pain  and  tenderness,  with  a  certain 
amount  of  oedema  and  hardness,  may  manifest  themselves  along  the 
course  of  the  inflamed  vessel.  These  symptoms,  however,  speedil3’'  give 
way  to  those  that  characterize  the  lowest  forms  of  ataxic  fever — such  as 
a  fluttering  pulse,  a  brown  tongue,  sordes  about  the  mouth  and  teeth, 


764 


DISEASES  OF  VEINS. 


with  much  anxiety  of  countenance,  diarrhoea,  vomiting,  extreme  pros¬ 
tration,  delirium,  and  death.  These  symptoms  are,  indeed,  due  to  the 
formation  of  pus  in  the  vein,  its  admixture  with  the  blood,  and  con¬ 
sequent  poisoning  of  the  system.  The  whole  danger  and  peculiarity 
of  diffuse  phlebitis  depend,  I  believe,  upon  this  circumstance ;  and  I 
w^ould,  therefore,  refer  for  the  consequence  and  treatment  of  this  form  of 
the  affection  to  the  chapter  on  P3^8emia  (p.  606).  In  phlebitis  there  are 
two  great  sources  of  danger,  viz.,  that  of  embolism  leading  to  sudden 
death  by  the  plugging  of  the  pulmonary  artery  in  the  adhesive,  and  of 
P3^aemia  in  the  diffuse  form  of  the  disease. 

The  Treatment  of  this  form  of  phlebitis  resolves  itself  into  that  of  its 
secondaiy  and  important  constitutional  condition — the  pj’^semia  to  which 
it  gives  rise  (p.  619). 


VARIX. 

Varix^  or  Varicose  Veins,  is  meant  a  dilated  condition  of  these 
vessels,  with  hj’pertrophy  of  their  coats,  giving  rise  to  oedema,  tension, 
weight,  and  pain  in  the  parts  thej^  supply — often  with  a  good  deal  of 
numbness,  difficulty  in  motion,  or  loss  of  power  in  the  affected  limb.  In 
other  cases,  their  pressure  on  the  nerves  of  the  part  (as  when  the  veins 
of  the  spermatic  cord  are  enlarged)  may  give  rise  to  very  severe  suf¬ 
fering. 

Appearance, — Varicose  veins  are  tortuous,  dilated,  and  sacculated; 
they  are  serpentine  in  their  course,  and  feel  thick  under  the  finger.  They 
ma}^  be  superficial  or  deep  seated ;  when  superficial,  the  disease  is  often 
limited  to  one  of  the  larger  venous  trunks  of  a  limb,  the  smaller  branches 
not  being  engaged.  This  we  commonly  see  to  be  the  case  in  the  internal 
saphena  ;  in  other  cases,  the  small  cutaneous  veins  alone  ma3^be  affected, 
appearing  as  a  close  network  of  a  purplish-blue  color  under  the  skin, 
with  much  discoloration  of  parts,  and  some  oedema  of  the  limb;  or  both 
sets  of  vessels  may  be  implicated.  The  deep-seated  varix  is  not  by  any 
means  so  common  as  the  superficial;  and,  when  it  occurs,  is  generally’' 
the  result  of  the  pressure  of  a  tumor,  or  of  some  similar  cause.  Varicose 
veins,  especially"  when  superficial,  are  very  apt  to  infiame,  with  coagula¬ 
tion  of  the  blood  within  their  sinuses. 

Loeality. — The  veins  of  the  skin  and  the  mucous  membranes  are 
those  that  are  most  liable  to  varix.  It  is  most  commonly  met  with  in 
the  legs,  and  more  particularly"  in  the  trunk  of  the  internal  saphena  ;  but 
any  of  the  superficial  veins,  as  of  the  arms,  chest,  head,  neck,  hyq^ogas- 
trium,  or  thorax,  may  be  affected.  The  veins  about  the  anus  are  espe¬ 
cially  liable  to  varix,  constituting  some  forms  of  pile;  the  spermatic 
veins,  also,  very  often  become  enlarged,  constituting  varicocele.  As  a 
general  rule,  superficial  varix  is  infinitely  more  common  in  the  lower  than 
in  the  upper  part  of  the  body,  owing  evidently  to  the  tendency  of  the 
gravitation  of  blood  in  the  more  dependent  situations.  When  occurring 
at  any  point  above  the  pelvis,  it  may"  be  looked  upon  as  arising,  in  all 
probability",  from  the  pressure  of  a  tumor  of  some  kind  upon  the  large 
venous  trunks.  The  deep-seated  veins  that  are  principally  affected  are, 
the  internal  jugulars,  the  vena  azygos,  and  the  veins  of  the  prostate. 

Causes. — The  causes  of  varix  are  generally  such  conditions  as  induce 
more  or  less  permanent  distension  of  the  veins.  Thus,  for  instance, 
strains,  and  habitual  over-exertion  of  a  part,  by  driving  the  blood  into 
the  subcutaneous  veins,  may  give  rise  to  their  distension ;  so  also,  cer¬ 
tain  occupations  may  favor  gravitation  of  blood  to  the  lower  part  of  the 


VARICOSE  VEINS. 


765 


body ;  again,  the  length  of  a  vein,  as  of  the  internal  saphena,  may  occa¬ 
sion  its  dilatation  by  the  weight  of  the  long  column  of  the  contained 
blood.  Any  obstacle  to  the  return  of  the  blood  from  a  vein  (as  the  pres¬ 
sure  of  a  tight  garter  below  the  knee,  or  of  a  tumor  upon  one  of  the  large 
venous  trunks)  may  give  rise  to  its  permanent  distension,  as  well  as  to 
that  of  all  its  branches.  In  other  cases  the  affection,  or  the  disposition  to 
it,  appears  to  be  hereditary ;  and  in  many  instances  it  is  difficult  to 
recognize  any  cause  except  an  enfeebled  and  relaxed  state  of  the  walls  of 
the  vessel,  such  as  is  met  with  in  tall,  debilitated,  and  phlegmatic  people. 
Age  influences  materially  the  occurrence  of  the  disease,  which  is  rare  in 
the  earlier  periods  of  life,  but  gradually  increases  as  the  individual  ad¬ 
vances  in  years.  In  icomen^  especially,  the  affection  is  common ;  in  conse¬ 
quence,  partly',  of  natural  debility,  but  more  frequently  from  the  pressure 
of  the  enlarged  uterus  during  pregnancy. 

Structure. — Varicose  veins  are  sometimes  simply  dilated,  without 
any  thickening ;  but  in  other  instances  the}'  are  truly  hypertrophied, 
their  cavities  being  dilated  and  their  walls  thickened — the  vessel  like¬ 
wise  being  elongated,  forming  curves,  and  bending  back  on  itself.  Some¬ 
times  the  enlargements  at  particular  points  appear  .to  be  multilocular, 
the  vein  forming  a  series  of  curves  and  dilatations  together.  The  valves 
are  always  insufficient  in  varicose  veins,  being  usually  bent  backwards 
or  ruptured ;  and  the  lining  membrane  is  marked  by  longitudinal  striae. 
The  blood  in  these  vessels  has  a  tendency  to  coagulate  in  large  masses, 
the  vein  being  at  times  the  seat  of  inflammation,  by  which  this  tendency 
is  materially  assisted.  The  neighboring  and  subjacent  parts  are  much 
modified  in  structure  ;  and  there  is  usually  chronic  oedema,  wdtli  infiltra¬ 
tion  of  the  skin  and  areolar  tissue,  which  may  at  last  run  into  ulceration 
— giving  rise  to  the  varicose  ulcer,  which  has  already  been  described 
(p.  151),  and  which,  if  communicating  with  a  large  branch,  may  yield  a 
.copious  or  even  fatal  hemorrhage.  The  blood  contained  in  the  varicose 
knots  and  veins  becomes  more  or  less  stagnant,  and  probably  altered  in 
its  qualities,  so  as  to  render  the  vessels  peculiarly  liable  to  inflammation, 
and  possibly  even  to  injure  the  general  health  to  a  remarkable  degree. 

Treatment. — This  must  be  conducted  on  two  principles — to  palliate 
and  to  cure.  The  Palliative  Treatment  consists  in  moderate  compres¬ 
sion  exercised  upon  the  vessel,  so  as  to  support  its  weakened  and  dilated 
coats,  and  thus  prevent  its  further  distension  and  the  pain  occasioned  by 
this,  as  well  as  the  other  consequences — such  as  oedema,  disorganization, 
and  ulceration.  The  pressure  must  be  applied  very  smoothly  and  evenly, 
lest  it  irritate  and  ulcerate  the  skin,  or  produce  distension  of  the  vein 
below  the  part  compressed.  For  the  purpose  of  compression,  bandages 
and  elastic  stockings  are  commonly  employed.  In  some  cases,  elastic 
pressure  by  means  of  a  vulcanized  India-rubber  band  or  garter  may  be 
applied  around  the  limb,  so  as  to  stimulate  the  action  of  the  valves  of 
the  vein  ;  by  compression  it  cuts  off  the  weight  of  the  column  of  blood 
from  the  terminal  branches.  In  other  cases,  the  application  of  a  truss 
to  the  upper  part  of  the  saphena  vein,  as  recommended  by  Colles,  may 
be  of  service. 

If  a  varix  of  the  veins  of  the  leg  burst,  violent  bleeding  may  suddenly 
take  place  so  as  to  induce  faintness,  and  even  death.  The  copiousness  of 
the  bleeding  may  be  accounted  for  by  its  occurring  from  the  cardiac  side 
of  the  varix,  the  insufficiency  of  the  valves  not  presenting  the  ordinary 
obstacle  to  the  downward  flow  of  blood.  The  treatment  consists  in  laying 
the  patient  flat  on  the  floor  and  raising  his  leg,  when  the  hemorrhage  will 


766 


DISEASES  OF  VEINS. 


cease.  It  may  be  permanently  arrested  by  the  pressure  of  a  compress 
and  bandage. 

In  certain  circumstances,  it  becomes  necessary  to  change  the  palliative 
for  a  Curative  plan.  This  is  especially  requisite  in  the  following  three 
conditions:  1,  if  the  varix  be  so  large  as  to  produce  much  inconvenience, 
or  to  give  rise  to  severe  pain  by  its  pressure  on  the  nerves  in  its  neigh¬ 
borhood  ;  2,  if  a  varicose  vein  have  burst,  or  be  on  the  point  of  giving 
way;  or,  3,  if  an  ulcer  dependent  on  its  existence  will  not  heal.  Various 
plans  of  curative  treatment  have  been  recommended;  all  of  which  have 
for  their  object  the  obliteration  of  the  vein  at  one  point  by  exciting  adhe¬ 
sive  inflammation  there,  and  thus  causing  it  eventually  to  degenerate 
into  a  fibro-cellular  cord.  In  this  way  the  trunk  of  a  varicose  vein  and 
the  larger  masses  of  varix  may  be  occluded.  But  can  the  disease  be 
cured  by  the  local  obliteration  of  the  vein  ?  To  this  question  I  have  no 
hesitation  in  answering  in  the  negative.  Though  the  trunk  be  obliterated, 
a  collateral  venous  circulation  is  set  up,  which  is  very  apt  in  the  course 
of  a  few  months  to  take  on  a  varicose  condition,  and  thus  to  cause  a 
return  of  the  disease.  But,  though  the  cure  be  not  radical,  much  benefit 
ma}'^  often  be  effected  b}'^  removing  varicose  knots  that  occasion  pain  or 
inconvenience,  by  enabling  an  ulcer  to  cicatrize,  or  by  occluding  a  vein 
from  which  hemorrhage  has  occurred.  The  principle  of  all  curative 
treatment  in  varix  consists  in  exciting  adhesive  and  localized  inflamma¬ 
tion  in  the  vein  so  as  to  occlude  it,  and  thus,  by  directing  the  blood  into 
other  channels,  to  relieve  the  distension  of  the  diseased  vessels  and  the 
inconvenient  results  that  follow  this.  As  the  treatment  thus  necessarily 
involves  the  artificial  excitation  of  phlebitis,  there  is  always  some  little 
risk  of  the  inflammation  passing  be3^ond  the  adhesive  stage  into  that  of 
suppuration,  or  diffuse  inflammation. 

Various  plans  for  obliterating  the  veins  have  been  recommended. 
They  resolve  themselves  into  five  principal  heads  of  treatment. 

1.  The  subcutaneous  section  of  the  vein,  or  the  excision  of  an  inch  or 
so  of  the  vessel.  This  plan  of  treatment  is  severe  and  not  unattended 
by  danger,  as  we  learn  from  Brodie. 

2.  It  has  been  recommended  b}^  Mayo,  Seutin,  Bonnet,  and  others,  to 
excite  inflammation  in  the  vein  by  producing  a  series  of  deep  eschars  or 
issues  in  the  skin  covering  it,  by  the  application  of  a  caustic,  such  as  the 
chloride  of  zinc  or  potassa  fusa.  Skey  speaks  very  favorably  of  this 
mode  of  obliterating  varicose  veins,  as  being  devoid  of  danger.  He 
recommends  the  eschars  to  be  made  by  the  application  of  a  powder,  com¬ 
posed  of  three  parts  of  lime  and  two  of  potass,  made  into  a  paste  with 
spirits  of  wine  at  the  time  of  application.  The  eschars  should  not  be 
larger  than  a  split  pea,  and  their  number  must  depend  on  the  extent  of 
the  disease. 

3.  Others  recommend  the  obliteration  of  the  vessel  by  introducing 
needles  into  it,  and  transmitting  a  galvanic  current  along  and  across 
them.  Of  this  plan  of  treatment  I  have  not  had  an}’’ experience ;  nor  do 
I  believe  that  it  is  ever  emplo^^ed  by  Surgeons  in  this  country. 

4.  Injection  of  the  varix  by  a  few  drops  of  a  solution  of  the  per  chloride 
of  iron,  as  recommended  by  Pravaz,  is  a  very  effectual  method  of  pro¬ 
curing  coagulation  of  the  contained  blood  and  consolidation  of  the  varix, 
more  particularly"  if  it  be  very  large  and  cellular.  In  employing  this 
means,  it  is  better  to  compress  the  vein  by  means  of  the  finger  or  a  pad 
and  bandage  above  the  varix  ;  the  solutionis  then  to  be  injected  in  very 
small  quantity" — not  more  than  three  or  four  drops — by  means  of  the 
syringe  (which  will  be  described  in  speaking  of  the  treatment  ofnsevus), 


OBLITERATION  OF  VARICOSE  VEINS. 


767 


into  the  dilated  veins.  Coagulation  of  the  blood  immediately  takes  place. 
The  patient  must  be  confined  to  his  bed  for  a  few  days  with  the  limb 
raised,  and  a  bandage  should  be  applied  before  he  is  allowed  to  walk 
about.  This  means  is  very  effectual  in  large  varix,  and  may  in  such  cases 
be  advantageously  conjoined  with  the  next  method — the  pins  being  used 
under  the  venous  trunks,  and  the  solution  introduced  into  the  dilated 
masses  of  the  varix.  But  it  is  not  devoid  of  danger:  accidents,  such  as 
local  suppuration  and  sloughing,  pymmic  symptoms,  and  even  fatal  em¬ 
bolism,  have  followed  its  use. 

5.  The  most  convenient  and  safest  way  of  obliterating  the  vein  in  my 
opinion,  and  that  which  I  always  employ,  consists  in  compressing  the 
vessel  at  several  points,  by  passing  a  harelip  pin  underneath  it,  laying 
a  piece  of  wax-bougie  over  it,  and  then  applying  the  twisted  suture 
around  the  pin  and  over  the  bougie  (Fig.  253  a).  In  this  way  the  vessel 

Fig.  253. 


Application  of  Pins  to  Varicose  Veins. 


gradually  ulcerates  b}^  the  pressure  that  is  exercised  upon  it,  and  the 
presence  of  the  bougie  prevents  the  ligature  from  injuring  the  skin.  In 
performing  this  operation,  care  must  be  taken  that  the  vein  be  not  trans¬ 
fixed,  but  that  the  pin  be  pushed,  or  rather  dipped,  underneath  it ;  the 
ligature  should  not  be  too  thin,  and  must  be  applied  tightl^^  over  the 
bougie;  several  pins  (as  many  as  eight  or  ten,  if  necessary)  should  be 
introduced  along  the  course  of  the  same  vessel,  at  distances  of  about 
three-quarters  of  an  inch  from  one  another  (Fig.  253)  ;  those  highest  up 
should  be  put  in  first,  and  they  should  be  left  in  for  at  least  a  week  or 
ten  days,  by  which  time  the  obliteration  of  the  vessel  will  have  taken 
place.  I  believe  that  all  the  danger  of  the  operation  consists  in  the 
transfixion  of  the  vein  by  the  pin;  the  operator  may  always  know  when 
he  has  done  this  bj’^  the  escape  of  a  few  drops  of  venous  blood;  when  the 
pin  is  properly  passed  under  the  vein,  the  operation  is  a  perfectly  blood¬ 
less  one.  If  the  vein  be  transfixed,  the  pin  should  immediately  be  with¬ 
drawn  and  passed  at  another  point ;  if  it  be  allowed  to  remain  in  the 
vein,  it  will  act  as  a  foreign  body,  and  suppurative  phlebitis  will  ensue. 
When  the  vein  is  properly  compressed  between  the  pin  below  and  the 
bougie  above,  adhesive  inflammation  takes  place  in  it,  and  it  becomes 
obliterated  at  the  point  of  pressure.  By  attention  to  these  circumstances 
I  have  never  met  with  any  ill  consequences,  either  from  suppurative  phle¬ 
bitis  or  pyaemia,  in  any  of  the  cases  in  which  I  have  performed  this  opera¬ 
tion,  which  are  several  hundreds  in  number. 

In  addition  to  the  application  of  the  pins  in  the  usual  way,  H.  Lee 


768 


ANEURISM  BY  ANASTOMOSIS,  AND  N^VUS. 


has  recommended  the  subcutaneous  division  of  that  portion  of  the  vein 
'which  is  included  between  them,  after  coagulation  of  the  blood  has  taken 
place.  This  I  have  found  to  be  an  useful  addition  to  the  ordinary  treat¬ 
ment,  and  to  insure  the  obliteration  of  the  vessel. 

The  points  of  the  pins  may  be  prevented  from  pressing  injuriously 
upon  the  skin,  by  putting  small  pieces  of  adhesive  plaster  under  them. 
The  powers  of  the  constitution  should  at  the  same  time  be  improved,  and 
the  activity  of  the  circulation  kept  up  by  nourishing  diet,  tonics,  and 
wine.  Whilst  the  pins  are  in,  the  patient  must  not  be  allowed  to  move 
about,  and  after  they  have  been  taken  out  the  limb  should  be  bandaged 
for  some  time.  In  general,  no  ulceration  takes  place  about  the  pinhole 
apertures ;  but  occasionally,  in  debilitated  constitutions,  a  sore  forms, 
which  requires  to  be  treated  on  ordinary  principles. 


CHAPTER  XLI. 

ANEURISM  BY  ANASTOMOSIS,  AND  N^YUS.— HEMORRHAGIC 

DIATHESIS. 

ANEURISM  BY  ANASTOMOSIS. 

Aneurism  hy  Anastomosis  is  a  disease  of  the  arteries,  in  which  the 
vessels  become  excessively^  elongated,  tortuous,  and  serpentine ;  some¬ 
times  they'  assume  a  varicose  condition,  being  dilated  into  small  sinuses, 
and  are  always  very  thin  walled,  resembling  rather  veins  than  arteries 
in  structure.  This  kind  of  dilatation  of  the  vessels  will  give  rise  to 
pulsating  tumors,  often  of  considerable  size,  and  of  a  veiy  active  and 
dangerous  character.  They'  may  be  situated  in  almost  any'  tissue  or 
organ  of  the  body*,  but  are  most  commonly'  met  with  in  the  submucous 
and  subcutaneous  areolar  tissue,  and  most  frequently'  occur  in  the  upper 
part  of  the  body',  especially'  about  the  scalp,  orbit,  lips,  and  face ;  but 
they  have  been  met  with  in  other  situations,  such  as  the  tongue,  and 
even  in  internal  organs,  as  the  liver ;  and  I  have  seen  very'  active 
growths  of  this  kind  on  the  side  of  the  chest,  nates,  and  foot.  In  some 
cases,  aneurism  by  anastomosis  occurs  in  bones,  in  which  it  forms  a 
special  disease,  and  is  not  uncommonly  associated  with  encephaloid. 
Indeed,  there  is  certainly^  a  great  tendency'  for  aneurism  by  anastomosis 
and  encephaloid  to  run  into  one  another ;  the  limits  between  them  not 
being  very  clearly  defined,  especially  when  they'  occur  in  connection 
with  osseous  tissue.  It  will  generally  be  found  that  the  arteries  leading 
to  the  aneurism  by  anastomosis,  though  at  a  considerable  distance  from 
it,  are  tortuous  and  enlarged,  with  thin  and  expanded  coats,  and  pulsate 
actively' ;  in  fact,  constituting  that  condition  that  goes  by  the  name  of 
Cirsoid  Dilatation  of  the  vessels. 

Aneurism  by  anastomosis  forms  tumors  of  vaiying  magnitude  and 
irregular  shape ;  they'  are  usually'  of  a  bluish  color,  have  a  spongy  feel, 
are  readily^  compressible,  not  circumscribed,  and  have  large  tortuous 
vessels  running  into  and  from  them  on  diflferent  sides.  Their  tempera¬ 
ture  is  generally'  above  that  of  neighboring  parts;  and  a  vibratory  or 
purring  thrill,  amounting  in  many'  cases  to  distinct  pulsation,  may'  be 
felt  in  them.  This  pulsation  or  thrill  is  synchronous  with  the  heart’s 


ANEURISM  BY  ANASTOMOSIS. 


769 


beat,  may  be  arrested  b}"  compressing  the  tumor  or  the  arteries  leading 
to  it,  and  returns  with  an  expansive  beat  on  the  removal  of  the  pressure. 
The  bruit  is  often  loud  and  harsh,  but  at  other  times  of  a  soft  and  blow¬ 
ing  character.  These  growths  rareh^  occur  in  infanc}^,  but  generally 
make  their  appearance  in  3'oung  adults,  though  they  may  be  met  with 
at  all  periods  of  life,  often  as  the  consequence  of  injur3^ 

Diagnosis. — It  is  of  importance  to  effect  the  diagnosis  between 
ordinary  aneurism  and  that  b}’  anastomosis.  In  man}"  cases  the  situa¬ 
tion  of  the  tumor  at  a  distance  from  any  large  trunk,  as  on  the  scalp, 
the  outside  of  the  thigh,  or  the  gluteal  region,  will  determine  this. 
Again,  the  outline  of  the  growth  is  less  distinct  than  in  true  aneurism  ; 
and  tortuous  vessels  will  be  felt  leading  to  it  from  different  directions. 
The  swelling  also  is  doughy  and  very  compressible;  but,  when  the 
pressure  is  removed,  the  blood  enters  it  with  a  whiz  and  thrill,  not  with 
the  distinct  pulsating  stroke  that  is  found  in  aneurism.  The  pulsation, 
not  so  forcible  as  in  aneurism,  is  more  heaving  and  expansive.  The 
bruit  is  louder  and  more  superficial,  sometimes  having  a  cooing  note. 
By  pressure  on  the  arteries  leading  to  the  tumor  these  signs  are  usually 
not  entirely  arrested,  though  diminished  in  force,  the  blood  entering  it 
from  the  neighboring  parts,  and  in  a  less  direct  way. 

Treatment. — The  treatment  of  aneurism  by  anastomosis  must  de¬ 
pend  upon  the  size  and  situation  of  the  growth.  When  it  is  so  placed 
that  it  can  be  ligatured  or  excised^  as  on  the  lip,  or  when  small,  about 
the  neck,  face,  or  scalp,  trunk,  or  extremities,  it  should  be.  removed.  I 
always  prefer  the  ligature,  applied  as  will  immediately  be  described,  as 
being  the  safest,  and  upon  the  whole  the  readiest  mode  of  removing  such 
a  tumor.  If  excision  be  practised,  it  is  necessary  to  be  very  careful  to 
cut  widely  of  the  disease;  if  it  be  cut  into,  fearful  hemorrhage  may 
ensue,  which  can  only  be  arrested  by  pressure,  and  which  in  several 
instances  has  proved  fatal. 

If  the  disease  be  very  large  and  extended,  as  is  commonly  seen  on  the 
scalp,  or  if  deeply  seated,  as  in  the  orbit,  neither  ligature  nor  excision  of 
the  tumor  can  be  practised,  and  it  becomes  necessary  to  starve  it  by 
cutting  off  its  supply  of  blood.  This  may  be  done  either  by  ligaturing 
the  principal  branches  leading  to  it^  or  the  main  trunk  of  the  limb  or 
part. 

Simple  ligature  of  the  arterial  branches  leading  to  the  tumor  has 
never,  I  believe,  been  followed  by  success  ;  at  least,  in  ten  recorded  in¬ 
stances  in  which  it  has  been  had  recourse  to,  the  disease  has  not  in  one 
instance  been  cured.  It  has,  however,  been  successfully  conjoined  by 
Gibson,  in  two  cases  of  aneurism  by  anastomosis  of  the  scalp,  with  in¬ 
cisions  made  round  the  tumor  at  intervals  between  the  principal  feeding 
arteries,  which  at  the  same  time  were  tied. 

The  main  trunk  leading  to  the  tumor  has  been  ligatured  in  a  con¬ 
siderable  number  of  cases.  The  brachial  and  femoral  arteries  have  been 
tied  for  disease  of  this  kind  situated  on  the  extremities,  and  in  some 
instances  with  success ;  but  the  carotid  is  the  vessel  that  has  been  most 
frequently  deligated,  in  consequence  of  the  tumor  being  commonly 
situated  on  the  scalp  and  in  the  orbit.  This  operation  has  been  done 
in  twenty-three  recorded  cases,  and  in  five  instances  both  the  carotids 
were  ligatured  at  intervals  of  several  weeks.  In  all  of  those  cases  in 
which  the  double  operation  was  performed,  the  patients  ultimately  re¬ 
covered.  In  some  of  the  cases  in  which  one  carotid  alone  was  tied,  the 
disease,  being  seated  upon  the  scalp,  was  not  cured ;  and  it  was  after- 
VOL.  u— 49 


770 


N^VUS. 


wards  found  necessary  to  have  recourse  to  ligature  of  the  tumor,  to 
excision,  and  to  other  means  of  removal;  indeed,  when  seated  upon  the 
scalp,  this  disease  appears  to  be  more  intractable  than  in  any  other  part 
of  the  body,  owing  probabl}'  to  the  freedom  of  the  arterial  suppl}"  from 
the  numerous  vessels  that  ramif}'  in  this  region.  Here,  however,  much 
benefit  might  be  derived  after  ligature  of  the  carotid,  b}'  adopting  the 
plan  suggested  b}"  Gibson  of  tying  the  feeding  arteries,  and  making 
incisions  between  them  down  to  the  bone.  The  ligature  of  the  carotid 
has  answered  best  for  diseases  of  this  kind  in  the  orbit;  of  thirteen  in¬ 
stances  in  which  the  artery  has  been  tied  for  aneurism  by  anastomosis 
in  this  situation,  a  cure  was  accomplished  in  the  majorit}'. 


N^YUS. 

This  disease,  under  which  are  included  those  various  affections  termed 
Mother^’s  2Iarks^  Erectile  Tumors^  and  Vascular  Groic^/is,  constitutes  an 
important  and  interesting  section  of  surgical  affections.  It  appears  to 
consist  essential!}'  in  an  excessive  development  of  the  vascular  tissue 
of  a  part,  and  differs  greatly  as  to  nature,  cause,  and  treatment;  accord¬ 
ing  as  the  arterial,  the  capillaiy,  or  the  venous  elements  of  the  tissue 
predominate.  The  predominance  of  the  arterial  tissue  we  have  already 
considered,  under  the  head  of  Aneurism  b}'  Anastomosis  ;  it  now  remains 
for  us  to  describe  the  Capillaiy  and  Venous  Xsevi. 

Capillary  Naevi  appear  as  slightly  elevated  but  flat  spots  on  the 
skin,  of  a  bright  red  or  purplish  tint,  and  having  occasionally  granular 
or  palpillated  elevations,  with  some  larger  vessels  ramifying  on  their  sur¬ 
face.  The}'  often  spread  superficially  to  a  considerable  extent;  they 
are  usually  situated  on  the  face,  head,  neck,  or  arms,  but  occasionally, 
though  more  rarely,  on  the  back,  the  nates,  the  organs  of  generation, 
and  the  lower  extremities.  They  are,  I  believe,  always  congenital, 
though  often  at  birth  very  small,  not  larger  than  a  pin’s  head,  from 
which  they  may  spread  in  the  course  of  a  few  weeks  or  months  to 
patches  an  inch  or  two  in  diameter.  In  many  cases  no  inconvenience 
results  from  this  disease,  except  the  deformity  it  entails  ;  but  occa¬ 
sionally,  more  especially  when  the  growth  is  at  all  prominent,  there  is  a 
great  disposition  to  unhealthy  and  hemorrhagic  ulceration.  When  bleed¬ 
ing  occurs,  it  is  usually  in  a  trickling  stream,  and  without  any  degree 
of  force. 

Venous  Naevi  are  of  a  dark  purple  or  reddish  color,  usually  very 
prominent,  and  often  forming  distinct  tumors  of  considerable  size,  which 
may  either  be  smooth  and  ovoid,  or  else  somewhat  lobulated.  On  com¬ 
pressing  a  growth  of  this  kind,  it  subsides  to  a  certain  extent,  feeling 
doughy,  soft,  and  inelastic  ;  and  on  the  removal  of  the  pressure  fills  again. 
In  some  cases,  when  consolidated  by  inflammation,  or  containing  cysts, 
it  cannot  be  lessened  in  bulk  by  pressure.  These  naevi  are  usually  of 
about  the  size  of  half  a  walnut,  but  sometimes  much  larger.  I  have 
removed  from  the  nates  and  the  back  some  fully  as  large  as  oranges. 
They  less  frequently  occur  upon  the  head  and  face  than  the  capillary 
form  of  the  disease ;  most  of  the  instances  that  I  have  seen  have  been 
met  with  in  the  lower  part  of  the  body,  about  the  nates,  back,  lower 
extremities,  and  organs  of  generation. 

Subcutaneous  naevi  are  occasionally  of  a  mixed  character^  forming 
soft,  doughy,  and  compressible  tumors,  capable  of  diminution  by  pres¬ 
sure,  on  the  removal  of  which  they  slowly  fill  out  again  to  as  large  a 


TREATMENT  OF  N^VUS. 


771 


size  as  before;  they  also  become  distended  when  the  child  screams  or 
struggles,  and  are  usually  oval,  smooth,  and  uniform.  The  skin  covering 
the  tumor  is  often  unaffected  ;  at  other  times  it  is  implicated  in  an  oval 
patch  on  the  most  prominent  part  of  the  growth,  and  occasionallj^  the 
surrounding  veins  are  bluish  and  enlarged. 

Structure. — CapillaiT  nmvi  appear  to  be  composed  of  a  congeries  of 
small  tortuous  capillary  vessels ;  venous  nmvi  appear  made  up  of  thin 
tortuous  veins,  dilated  into  sinuses  and  small  pouches.  In  the  midst 
of  these  masses,  cysts  are  not  uncommonly  found,  sometimes  containing 
clear,  at  other  times  dark,  sanguinolent  fluid.  These  cysts  are  probably 
venous  sinuses,  the  openings  into  which  have  become  occluded. 

Treatment. — In  the  treatment  of  njevus,  the  first  point  to  be  deter¬ 
mined  is  whether  the  case  should  be  left  to  nature,  or  whether  operative 
measures  should  be  had  recourse  to.  In  deciding  this  point  we  must  be 
guided  b}'  the  size,  situation,  and  character  of  the  morbid  growth.  If 
this  be  small,  cutaneous,  and  superficial,  so  situated  that  it  occasions 
little  or  no  disfigurement,  and  if  it  show  no  tendency  to  increase,  it  may 
be  left  without  interference ;  when  it  may  eventually  shrivel  and  disap¬ 
pear,  or  become  converted  into  a  kind  of  mole.  In  some  cases  this  pro¬ 
cess  may  be  hastened  bj*  the  application  of  tincture  of  iodine  or  liquor 
plumbi.  In  other  cases,  again,  the  noevus,  though  cutaneous  and  super¬ 
ficial,  is  so  widel}'  diffused  over  the  surface,  that  no  attempt  at  its 
removal  or  destruction  can  be  entertained  with  prudence. 

But,  if  the  naevus  be  large,  if  it  be  subcutaneous,  or  if  it  increase  in 
size,  or  if  it  be  so  situated  as  to  occasion  disfigurement, 
means  must  then  be  adopted  for  its  removal  by  operative  Fig.  254. 
procedure. 

Operations  for  the  removal  of  naevi  may  be  conducted 
on  five  principles:  1,  to  excite  adhesive  inflammation  in 
them,  and  so  to  produce  plugging  and  obliteration  of  the 
vascular  tissue  of  which  the}’  are  composed;  2,  to  destro}’’ 
the  growth  b}’  caustics ;  3,  to  remove  it  b}^  the  galvanic 
cautery;  4,  to  remove  it  with  the  knife;  or,  5,  to  remove 
it  b}’  ligature.  Each  of  these  different  plans  of  treat¬ 
ment  is  peculiarl}’  applicable  when  the  disease  assumes 
certain  forms,  and  affects  certain  situations. 

1.  AYhen  the  nievus  is  of  small  size,  and  occurs  in 
such  situations  that  its  destruction  by  caustics,  or  re¬ 
moval  b}’  knife  or  ligature,  would  be  attended  by  se¬ 
rious  deformit}’,  as  when  it  is  seated  about  the  eyelids, 
upon  the  tip  of  the  nose,  at  the  inner  angle  between  the 
eve  and  the  nose,  or  about  the  corners  of  the  mouth,  it  is 
best  to  endeavor  to  procure  its  obliteration^  by  exciting 
adhesive  inflammation  in  it.  This  may  be  done  in  various 
waj’s.  If  small,  the  nmvus  ma}’  be  vaccinated.  If  it  be 
larger,  the  most  convenient  plan  consists,  perhaps,  in 
passing  a  number  of  fine  silk  threads  across  the  tumor  in 
different  directions,  and  leaving  them  in  for  a  week  or  two 
at  a  time,  until  they  have  produced  sufficient  inflamma¬ 
tion  along  their  tracks,  then  withdrawing  them  and 
passing  them  into  other  parts  of  the  tumor.  In  this  way 
its  consolidation  ma}’  graduall}"  be  efiected.  Another 
very  useful  plan  is  to  break  up  the  substance  of  the 
growth  subcutaneously  by  means  of  a  cataract-needle,  or 
tenotome,  and,  in  the  intervals  between  the  different  in- 


Syringe  for  Inject¬ 
ing  Xaevi. 


772 


vus. 


troductioiis  of  this  instrument,  to  keep  up  pressure  upon  the  tumor. 
In  other  cases,  again,  the  requisite  amount  of  consolidation  will  be  in¬ 
duced  by  passing  acupuncture-needles  into  the  njevus,  and  then  heat¬ 
ing  them  b}^  means  of  a  spirit-lamp.  Perhaps  the  most  efficient  way  of 
obtaining  this  object  is  %  injecting  the  perchloride  of  iron  b}^  means 
of  a  small  glass  s^'ringe  with  a  screw-piston  rod  and  a  fine  sharply 
pointed  nozzle  (Fig.  254).  In  doing  this,  care  must  be  taken  that  but 
a  veiy  small  quantity  of  the  solution,  not  more  than  two  or  three  drops, 
be  injected  at  one  time.  The  perchloride  of  iron  possesses  extraordinaiy 
power  of  coagulating  the  blood;  and,  if  more  than  has  just  been  men¬ 
tioned  be  thrown  in,  the  tissue  of  the  njevus  ma}’  either  hare  its  vitality 
destro3’ed,  and  slough,  or  coagulation  of  the  blood  in  the  vessels  be)"ond 
the  nsevus  ma}"  occur,  and  a  dangerous  or  even  fatal  embolism  ensue 
from  the  coagulum  thus  formed  being  washed  into  the  current  of  the 
circulation. 

2.  When  the  nmvus  is  small,  ver}"  superficial,  of  the  capillar}^  character, 
with  an  exceedingly'  thin  covering  of  cuticle,  and  so  situated,  as  upon 
the  arm,  neck,  or  back,  that  a  moderate  amount  of  scarring  is  of  little 
consequence,  it  may  most  conveniently'  be  removed  by'  the  free  ajDplica- 
tion  of  nitric  acid.  This  should  be  well  rubbed  on  by  means  of  a  piece 
of  stick  ;  and,  after  the  separation  of  the  slough,  its  application  must  be 
repeated  as  often  as  there  is  any'  appearance  of  the  granulations  spring¬ 
ing  up,  which  occasionally'  happens  at  one  angle  of  the  wound,  and  indi¬ 
cates  a  recurrence  of  the  vascular  growth. 

3.  The  galvanic  cautery  has  been  used  in  a  large  number  of  cases  by 
continental  Surgeons,  especially  Middeldorpf  of  Breslau.  In  ISO  cases 
tabulated  by  Maas  of  Breslau,  this  treatment  was  completely'  successful 
in  112.  Eleven  were  improved  ;  3  died  ;  and  the  result  in  4  was  unknown. 
Of  the  130  cases,  34  were  capillary’'  naevi,  and  of  these  32  were  cured  : 
and  84  were  venous  naevi,  of  which  12  were  cured,  3  died,  and  8  were 
improved.  There  are  two  methods  by  which  naevi  may'  be  cured  by  the 
electric  cautery  :  viz.,  by'  electrolytic  action,  the  naevoid  structure  being 
.gradually^  consolidated  and  thus  removed  ;  and  secondly,  by^  the  cauter¬ 
izing  action  of  a  platinum  wire  made  red  hot. 

4.  When  the  naevus  is  large,  constituting  a  more  or  less  distinct 
tumor,  and  is  of  a  somewhat  venous  character,  it  may^  occasionally'  be 
'excised.  Teale,  junior,  has  shown  that  some  naevi  which  are  distinctly' 
•encapsuled  may'  readily'  be  dissected,  or  rather  shelled  out.  Should  the 
naevus,  however,  be  diffused,  without  any^  distinct  limiting  capsule,  care 
should  be  taken  to  cut  wide  of  the  disease  ;  and  no  operation  with  the 
knife  should  be  undertaken  unless  the  growth  be  either  so  situated,  as 
upon  the  lip,  that  the  parts  may'  readily  be  brought  or  compressed 
together,  or  upon  the  nates  or  thigh,  where  it  is  unconnected  with 
large  bloodvessels,  and  is  also  very  indolent  and  venous.  If  the  naevus 
be  arterial,  or  partake  of  the  nature  of  aneurism  by  anastomosis,  it 
should  not  be  touched  with  the  knife.  It  is  especially  when  the  naevus 
is  lipomatous  or  cy'stoid,  or  is  distinctly^  encapsuled,  that  excision  may 
be  advantageously  practised. 

5.  As  a  general  rule,  it  is  far  safer  and  more  convenient  to  extirpate 
the  growth  with  the  ligature ;  and  this,  indeed,  is  the  mode  of  treatment 
that  is  most  generally'  applicable  to  tumors  of  this  kind  in  whatever 
situations  they'  may'  occur,  as  it  effectually  removes  them  without  risk  of 
, hemorrhage,  and  leaves  a  sore  that  very'  readily'  cicatrizes. 

The  ligature  requires  to  be  applied  in  different  ways,  according  to  the 


LIGATURE  OF  NJEVUS, 


773 


size  and  situation  of  the  tumor.  In  all  cases,  the  best  material  is  firm, 
round,  compressed  whip-cord.  This  should  be  tied  as  tightly  as  possible, 
and  knotted  securely,  so  that  there  may  be  no  chance  of  any  part  of  the 
tumor  escaping  complete  and  immediate  strangulation.  It  is  well,  if 
possible,  not  to  include  in  the  noose  any  healthy  skin,  but  to  snip  across 
with  a  pair  of  scissors  that  portion  of  integument  which  intervenes 
between  the  cords  that  are  tied  together  ;  at  the  same  time,  care  must  be 
taken  to  pass  the  ligatures  well  beyond  the  limits  of  the  disease. 

When  the  tumor  is  small,  an  ordinaiy  double  ligature  may  be  passed 
across  its  base,  b}"  means  of  a  common  suture-needle  ;  and,  the  noose 
being  cut  and  the  thread  tied  on  each  side,  strangulation  will  be  effected. 
When  it  is  of  larger  size,  and  of  round  shape,  the  most  convenient  plan 
of  strangulating  the  tumor  is  that  recommended  by  Liston.  It  consists 
in  passing,  by  means  of  long  mevus-needles,  fixed  in  wooden  handles, 
and  having  the  e3’’e  near  their  points,  double  whip-cord  ligatures  in  oppo¬ 
site  directions  across  the  tumor ;  then  cutting  through  the  nooses,  and 
t3dng  together  the  contiguous  ends  of  the  ligatures  until  the  whole  of 
the  growth  is  encircled  and  strangled  by  them.  In  doing  this,  a  few 
precautions  are  necessaiy :  thus,  the  first  nsevus-needle  should  be  passed 
•across  the  tumor  unarmed  (Fig.  255),  and  used  to  raise  up  the  growth 


Fig.  255, 


Diagram  of  the  Applicatioa  of  Naevus-needles. 


somewhat  from  the  subjacent  parts.  The  second  needle,  armed  as  repre¬ 
sented  in  the  diagram  (Fig,  255),  canning  the  whip-cord  ligature  b3’’ 
means  of  a  piece  of  suture-silk,  should  be  passed  across  the  tumor  in  the 
opposite  direction  to,  but  underneath,  the  first  needle ;  the  armed  needle 
being  withdrawn,  the  ligature  is  carried  across;  and  the  first  one,  having 
been  armed  in  the  same  wa3^,  carries  its  noose  through  the  tumor  as  it 
is  drawn  out.  The  two  nooses  having  then  been  cut,  an  assistant  must 
seize,  but  not  draw  upon,  six  of  the  ligature  ends  ;  the  Surgeon,  then, 
having  divided  the  intervening  bridge  of  skin,  ties  rather  tightl3’’,  a  reef- 
knot,  the  two  ends  are  left  hanging  out ;  as  soon  as  he  has  done  this,  he 
proceeds  to  the  next  two,  and  so  on  to  the  last  (Fig.  256).  AYhen  he  ties 


774 


N^VUS. 


these,  he  must  do  so  with  all  his  force,  especiall}-  if 
the  tumor  be  large,  as  by  drawing  on  them  he 
tightens  all  the  other  nooses,  and  drags  the  knots 
towards  the  centre  of  the  growth,  which  is  thus 
effectually  strangled.  He  then  cuts  off  the  tails  of 
the  ligature.  After  the  tumor  has  sloughed  away, 
which  happens  in  a  few  days,  if  properly  and  tightly 
strangled,  the  wound  is  treated  on  ordinary  princi¬ 
ples.  If  the  nrevus  be  altogether  subcutaneous,  the 
skin  covering  it  should  not  be  sacrificed,  but,  being 
divided  by  a  crucial  incision,  many  be  turned  down 
in  four  flaps,  and  the  ligature  then  tied  as  directed. 

In  some  cases,  the  nsevus  is  so  flat  and  elongated  that  the  application 
of  the  quadruple  ligature,  as  above  described,  cannot  include  the  whole 
of  it.  In  these  circumstances,  I  have  found  the  ligature  about  to  be 
described  eminently  useful,  having  successfully  employed  it  in  a  great 
number  of  instances.  Its  great  advantage  is  that,  while  it  completely 
and  very  readily  strangles  the  tumor,  it  does  not  inclose  an  undue  quan¬ 
tity  of  integument,  and  thus  does  not  produce  a  larger  cicatrix  than  is 
necessary  for  the  eradication  of  the  disease.  It  is  applied  in  the  follow¬ 
ing  way.  A  long  triangular  needle  is  threaded  on  the  middle  of  a  whip¬ 
cord  about  three  yards  in  length  ;  one  half  of  this  is  stained  black  with 
ink,  the  other  half  is  left  uncolored.  The  needle  is  inserted  through  a 
fold  of  the  sound  skin,  about  a  quarter  of  an  inch  from  one  end  of  the 
tumor,  and  transversely  to  the  axis  of  the  same.  It  is  then  carried 
through,  until  a  double  tail,  at  least  six  inches  in  length,  is  left  hanging 
from  the  point  at  which  it  entered ;  it  is  next  carried  across  the  base  of 
the  tumor,  entering  and  passing  out  beyond  its  lateral  limits,  so  as  to 
leave  a  scries  of  double  loops  about  nine  inches  in  length  on  each  side 
(Fig.  251).  Every  one  of  these  loops  should  be  made  about  three-quar¬ 
ters  of  an  inch  apart,  including  the  space  of  the  tumor ;  and  the  last 


Fig.  257.  Fig.  258. 


Diagram  of  Ligature  of  Flat  and  Elongated  Nsevus. 


Fig.  256. 


Diagram  of  Nmvus  tied. 


loop  should  be  brought  out  through  a  fold  of  healthy  integument  beyond 
the  tumor.  In  this  way  we  have  a  series  of  double  loops,  one  white,,  and 
the  other  black,,  on  each  side  (Fig.  257).  All  the  ivhite  loops  should  now 
be  cut  on  one  side,  and  the  black  loops  on  the  other,  leaving  hanging 
ends  of  thread  of  corresponding  colors.  The  tumor  may  now  be  strangiq 


X^VI  OF  THE  HEAD  AND  FACE. 


775 


latecl  b}’  drawing  down  and  knotting  each  pair  of  ivhite  threads 

on  one  side,  and  each  pair  of  black  ones  on  the  other.  In  this  way  the 
tumor  is  divided  into  segments,  each  of  which  is  strangulated  by  a  noose 
and  a  knot :  b}"  black  nooses  and  lohite  knots  on  one  side,  b}’’  ivhite 
nooses  and  black  knots  on  the  other  (Fig.  258). 

Tlie  cicatrix  resulting  from  the  removal  a  nsevus  is  usually  firm  and 
healthy ;  Init,  in  some  instances,  I  have  seen  it  degenerate  into  a  hard 
wart}"  mass  requiring  subsequent  excision.  The  ligature  may  be  used 
successfulh"  at  all  ages.  I  have  repeatedly  tied  large  active  nmvi  in  in¬ 
fants  a  month  or  two  old  without  meeting  with  any  accident. 

Naevi  in  Special  Situations. — Naevi  of  the  Scalp  are  more  frequent 
than  in  an}"  other  situation,  except,  perhaps,  the  face.  When  occurring 
on  those  parts  that  are  covered  by  hair,  they  are  almost  invariably  pro¬ 
minent  and  subcutaneous  :  when  seated  on  the  forehead,  or  the  bare  skin 
behind  the  ears,  they  are  often  cutaneous.  The  ordinary  subcutaneous 
nmvus  of  the  scalp  is  readily  removed  by  the  application  of  the  quadruple 
ligature.  In  general,  it  is  better  not  to  attempt  the  preservation  of  any 
of  the  integument  covering  the  growth.  It  is  true  that,  when  removed, 
a  clean  white  cicatrix  is  left  which  never  covers  itself  with  hair ;  but  this 
contracts,  and  in  after  life  becomes  but  little  visible.  The  attempt  to 
dissect  down  the  skin  that  covers  the  naevus  is  not  only  troublesome,  but 
is  attended  by  very  considerable,  and  possibly  dangerous,  hemorrhage. 
Those  flat  naevi  that  are  situated  behind  the  ear  are  best  treated  by  the 
free  application  of  fuming  nitric  acid. 

Naevus  of  the  Fontanelle  is  the  most  important  variety  of  the  scalp- 
naevus,  and  constitutes  a  somewhat  formidable  disease.  A  large  purple 
tumor  is  situated  within  the  anterior  fontanelle,  rising  and  falling  with 
the  pulsations  of  the  brain  communicated  to  it,  and  becoming  distended 
and  tense  when  the  child  cries.  The  tumor  is  evidently  close  upon  the 
membranes  of  the  brain,  and  may  be  looked  upon  almost  as  an  intra¬ 
cranial  rather  than  a  scalp-tumor.  The  close  proximity  of  the  tumor  to 
the  brain  and  its  membranes  often  deters  practitioners  from  interfering 
with  it ;  and  I  not  unfrequently  see  cases  in  which  the  parents  of  the 
child  have  been  counselled  not  to  allow  any  operation  to  be  practised, 
lest  death  should  result.  Yet  this  tumor,  so  formidable  in  appearance, 
and  so  deeply  seated,  close  upon  the  brain,  and,  as  it  were,  within  the  cra¬ 
nium,  may  be  removed  with  perfect  safety  by  the  ligature.  I  have  often 
tied  nmvi  in  this  situation,  and  have  never  seen  any  ill  consequences,  not 
even  a  convulsive  fit,  occur.  The  danger,  then,  from  the  mere  strangula¬ 
tion  of  the  tumor  in  this  situation  cannot  be  great;  but  there  is  another  and 
a  special  danger,  viz.,  the  risk  of  wounding  the  membranes  of  the  brain 
in  passing  the  ligatures  under  the  base  of  the  tumor.  If  naevus-ueedles 
or  sharp-pointed  instruments  of  any  kind  be  used,  this  accident  will  be 
very  likely  to  occur;  and,  if  this  were  to  happen,  inevitably  fatal  conse¬ 
quences  must  ensue.  This  accident  may  always  be  avoided  by  operating 
hi  the  following  way.  A  puncture  is  made  in  front  of  the  tumor  through 
the  healthy  scalp.  An  eyed  probe,  armed  with  a  double  ligature,  is  then 
pushed  through  this  opening  across  the  base  of  the  tumor,  and  its  end  is 
made  to  project  on  the  opposite  side  beyond  it ;  here  another  puncture  is 
made,  and  the  probe  and  ligature  together  are  drawn  through.  The  same 
procedure  is  adopted  across  the  tumor  sideways.  In  this  way,  a  quadru¬ 
ple  ligature  is  passed  across  the  tumor  in  two  opposite  directions;  the  ends 
are  then  disengaged,  and  the  ligature  is  tightened  in  the  ordinary  way. 

Naevi  of  the  Face  are  of  very  common  occurrence,  and  usually  cause 
much  disfigurement.  The  treatment  to  be  adopted  necessarily  varies 


776 


N^VUS. 


greatly,  according  to  the  nature  of  the  naevus,  whether  cutaneous,  sub¬ 
cutaneous,  or  both  ;  and  especially  according  to  its  situation.  The  same 
plan,  which  is  advantageously  adopted  in  one  part,  may  be  altogether 
inapplicable  in  another.  We  shall,  accordingly,  consider  the  treatment 
of  these  vascular  growths,  as  they  alfect  the  eyelids,  the  nose,  the  cheeks, 
and  the  lips. 

Naevus  of  the  Eyelids  is  usually  cutaneous,  consisting  of  a  discolora¬ 
tion  or  staining,  as  it  were,  of  the  lid,  without  any  material  swelling. 
Such  a  disease  is,  I  think,  better  left  untouched ;  it  cannot,  of  course,  be 
removed  either  by  the  knife  or  by  caustics,  without  producing  worse 
results ;  and,  as  the  skin  is  always  deeply  involved,  milder  means  are 
inoperative,  or  possibly  equally  destructive.  I  have  heard  of  sloughing 
of  the  eyelid  being  occasioned  by  the  use  of  astringent  injections  ; 
though,  if  the  nsevus  were  subcutaneous,  and  constituted  a  distinct 
tumor,  passing  perhaps  into  the  orbit,  injection  with  the  perchloride  of 
iron  might  advantageously  be  adopted. 

Naevus  of  the  Nose  may  occur  in  two  situations — at  the  i*oot,  or  towards 
the  alse  and  apex.  When  seated  at  the  root  of  the  nose,  upon  the  bridge, 
or  at  the  lower  part  of  the  forehead,  between  and  perhaps  extending 
above  the  eyebrows,  it  is  often  subcutaneous,  and  may  attain  a  very  con¬ 
siderable  magnitude.  In  cases  of  this  kind,  I  have  found  the  quadruple 
ligature  the  readiest  means  of  removal;  and  although  the  part  included 
may  be  of  large  size,  the  resulting  cicatrix  is  wonderfully  small  and 
narrow,  usually  becoming  horizontal,  so  as  to  fall  into  the  folds  of  skin 
naturally  existing  in  that  situation.  In  the  case  of  a  little  girl  about 
three  3'ears  of  age,  brought  to  me  some  3^ears  ago  by  Gerber,  I  removed 
a  nmvus  that  was  cutaneous  as  well  as  subcutaneous,  and  as  large  as  a 
walnut,  from  this  situation,  by  means  of  the  quadruple  ligature,  with  the 
most  satisfactory  result,  the  resulting  cicatrix  being  remarkabh"  small; 
and  in  another  little  girl,  from  the  bridge  of  whose  nose  I  removed,  some 
3'ears  ago,  a  imevus  as  large  as  a  marble,  very  little  scarring  or  deformity’’ 
resulted.  In  both  these  cases,  the  nmvus  was  cutaneous  as  well  as  sub¬ 
cutaneous.  If  the  skin  be  not  affected,  injection  of  perchloride  of  iron 
may  be  advantageously  employed  in  such  cases.  When  the  tip  and  aim 
of  the  nose  are  affected,  the  naevus  being  cutaneous,  we  can  seldom  do 
much  to  improve  the  appearance  of  the  patient.  In  such  cases,  I  have 
tried  breaking  down  the  naevus,  and  the  galvanic  cautery,  without  any^ 
material  benefit;  the  destruction  of  the  tissues  soon  afterwards  leading 
to  deformity.  When  the  naevus  is  subcutaneous,  occup3dng  the  tip,  alae, 
and  columna  nasi,  injection  with  perchloride  of  iron  is  the  only  means 
that  I  have  found  of  real  service.  In  doing  this,  care  must  be  taken  not 
to  throw  in  too  much  of  the  liquid,  lest  sloughing  result. 

Naevi  of  the  Cheeks  may  occur  in  three  distinct  forms.  1.  There  may 
be  a  simple  cutaneous  naevus,  a  mere  staining  of  the  skin,  a  “  mother’s 
mark.”  This  admits  of  no  treatment ;  and  the  subject  of  it  must  submit 
to  continue  throu2:h  life  to  exhibit  the  characteristic  discoloration.  2. 
The  elevated  cutaneous  naevus  may  be  raised  above  the  surface,  being  of 
a  deep  purplish-red  or  plum  color,  and  covered  with  a  very  thin  integu¬ 
ment.  Ill  this  form  of  the  disease,  I  think  that  the  application  of  con¬ 
centrated  nitric  acid  is  the  best  means  of  extirpation.  By  one  or  two 
free  applications  of  the  caustic  the  naevus  growth  is  removed,  and  a  dense 
white  cicatrix,  presenting  little  disfigurement,  is  left  in  its  place.  3.  The 
naevus  may  involve  the  whole  thickness  of  the  cheek,  being  scarcely,  if 
at  all,  cutaneous.  Naevi  of  this  kind  cannot,  of  course,  be  extirpated, 
either  by  the  knife,  ligature,  or  caustics,  lest  the  cheek  be  perforated,  and 


NJEVI  OF  THE  LIPS. 


777 


the  most  serious  disfigurement  ensue.  In  such  cases  we  must  endeavor 
to  obliterate  the  structure  of  the  nsevus  by  exciting  inflammation  in  it 
by  setons,  or  by  breaking  down  the  structure  of  the  growth  with  cataract- 
needles  or  a  fine  tenotome.  In  a  case  which  I  attended  some  years  ago, 
with  Bartlett  of  Notting  Hill,  a  large  and  deeply  seated  nsevous  growth, 
which  occupied  one  cheek,  was  cured  by  having  a  number  of  fine  silk 
threads  passed  across  it  in  different  directions,  and  then  being  gradually, 
piece  b}^  piece,  broken  down  with  a  cataract-needle ;  no  disfigurement 
whatever  being  left. 

Naevi  of  the  Xzps  require  different  treatment,  according  as  they  occupy 
the  margin  or  have  involved  the  whole  substance  of  these  parts.  When 
seated  at  the  margin,  as  projecting  and  somewhat  pendulous  growths, 
they  may  very  readily  be  removed  by  a  double  or  quadruple  ligature, 
according  to  their  size.  This  was  the  practice  pursued  in  the  case  from 
which  the  accompanying  drawings  (Figs.  259,  260)  were  taken,  where  a 
most  excellent  result  was  obtained  bv  the  use  of  the  ligature,  followed 

V  0  7 


Xsevus  of  Lower  Lip:  Front  View.  .  Najvus  of  Lower  Lip  ;  Side  View. 

at  a  later  period  by  injection  of  perchloride  of  iron  into  some  of  the  more 
widely  diffused  parts  of  the  growth.  When  the  naevus  involves  the  whole 
thickness  of  the  lip,  such  measures  are  not  always  available.  If  it  deeply 
invade  the  substance  of  the  lips,  an  operation  somewhat  similar  to  that 
for  the  removal  of  a  cancroid  growth  might  be  practised;  the  whole  sub¬ 
stance  of  the  lip  being  cut  through  widely  on  each  side,  and  the  edges 
of  the  incision  brought  together  with  harelip  pins.  Such  an  operation 
is  only  practicable  when  the  disease,  though  deeply  seated,  does  not 
spread  to  any  very  great  extent  laterally.  When  it  does,  the  whole  of 
one  half  of  the  lip,  for  instance,  being  involved,  the  use  of  the  knife, 
especially  in  young  infants,  would  be  too  hazardous,  on  account  of  the 
probability  of  serious  hemorrhage ;  and  other  means  must  be  emploj^ed. 
I  have  tried  the  use  of  setons,  and  of  injections  with  perchloride  of  iron  ; 
but  not  with  any  advantage.  When  the  whole  substance  of  the  lip  is 
involved,  inclusion  and  strangulation  of  the  morbid  mass  by  means  of 
the  ligature  is  seldom  available;  the  amount  of  sloughing  being  very 
great,  and  the  child,  absorbing  the  putrescent  matters  from  the  sloughing 
mass  which  results,  incurring  the  danger  of  being  poisoned  from  this 
source.  In  an  infant  with  a  veiy  large  naevus,  including  one-half  of  the 
lip,  which  I  ligatured  at  the  Hospital  some  years  ago,  death  appeared  to 
result  from  this  cause.  One  of  the  most  formidable  cases  of  naevus  of 
the  lip  that  I  have  ever  had  to  do  with,  and  in  its  results  the  most  satis- 
factoiy,  was  sent  to  me  several  years  ago,  by  Budd  of  Barnstaple.  The 
patient,  a  little  girl  five  months  old,  was  noticed  at  birth  to  have  a  red 
streak  on  the  right  side  of  the  upper  lip;  this  rapidly  developed  into  a 
large  tumid  purple  naevus,  which,  when  the  case  came  under  m3’'  observa¬ 
tion,  was  about  the  size  of  a  large  walnut,  involving  the  whole  of  the 
structures  of  the  lip,  from  the  cutaneous  to  the  mucous  surfaces  ;  it  was 


778 


N^VUS. 


of  a  deep  mnlberr}^  color,  and  extended  from  the  median  line  of  the  lip 
to  the  angle  of  the  mouth  (Figs.  261,  262).  The  integnments  covering 

Fig.  262. 


Large  Naevusof  Upper  Lip  :  Side  View. 

the  growth  were  exceedingly  thin,  and  the  tumor  itself  was  in  the  liighest 
degree  vascular  and  active.  Excision  appeared  to  be  out  of  the  question  ; 
the  ligature  presented  little  to  recommend  it ;  injections  witli  the  per- 
chloride  of  iron  and  the  introduction  of  setons  were  successively  tried, 
but  neither  of  these  means  produced  any  effec  t  on  the  tumor,  whicli  com¬ 
menced  to  extend  upwards  into  the  nostril.  I  accordingly  determined 
on  using  caustics.  Nitric  acid  was  first  employed  ;  but,  as  this  did  not 
produce  sufficiently  deep  impression  on  the  growth,  I  Iiad  recourse  to  the 
potassa  cum  calce.  By  means  of  this,  tlie  tumor  was  gradually  removed  ; 
the  hemorrhage  which  occasionally  resulted  being  restrained  by  pres¬ 
sure.  Notwitlistanding  the  amount  of  tissue  destro3md,  the  resulting 
cicatrix  was  small,  resembling  that  of  a  badly  united  harelip.  Three 
years  afterwards,  the  child  was  brought  to  me  again,  and  I  was  much 
struck  by  the  wonderful  improvement  that  had  taken  place  since  the 
removal  of  the  nmvus.  The  lip  was  smooth,  the  cicatrix  in  a  great  de¬ 
gree  worn  out,  and  comparatively"  little  disfigurement  was  left  in  the 
countenance  of  an  exceedingly  pretty  and  engaging  child.  Finding, 
however,  that  the  lip  was  still  drawn  or  tucked  in  by  a  veiy  dense  band 
of  cicatricial  tissue,  whicli  caused  a  deep  depression  of  the  ala  on  that 
side,  I  divided  this,  and  the  result  was  most  satisfactory. 

Nsevim  of  the  Tongue  is  of  rare  occurrence.  I  have,  however  success¬ 
fully  operated  by  means  of  the  ecraseur  in  one  case,  in  which  the  whole 

of  the  free  extremity  of  the  organ  was  involved  (Fig. 
263).  The  particulars  will  be  found  in  Chapter  LIX. 

Ndemoftlie  Orgo.ni>  of  Generation  are  occasionally 
met  with  in  the  female,  but  rarely  in  the  male.  The 
only  instance  of  Naevus  of  the  Penzs  with  which  I 
have  met  occurred  in  the  case  of  a  gentleman  thirty- 
two  years  of  age,  who  consulted  me  some  ymars  ago 
for  a  growth  of  this  kind  as  large  as  a  walnut,  situ¬ 
ated  under  the  reflexion  of  the  preputial  mucous 
membrane.  It  had  existed  for  many  years  without 
giving  any  annoyance,  but,  as  it  had  of  late  begun 
to  enlarge,  und  occasionally- to  bleed,  he  was  desirous  to  have  it  removed. 
This  I  did  by  applying  the  quadruple  ligature,  after  having  dissected  down 
to  the  mucous  membrane. 

Nsem  of  the  Vulva  and  Pudendum  are  by'  no  means  imfrequent.  We 
have  had  several  instances  of  the  kind  in  the  Hospital  of  late  years. 
They  are  usually  venous,  often  attain  a  large  size,  and  may  sometimes 
involve  the  integumental  structures  on  the  inside  of  the  thigh,  or  on  the 
perinreinn,  as  well  as  the  vulva.  When  the  growth  is  confined  to  the 
vulva,  it  is  best  removed  by  the  ligature.  Some  time  ago,  1  removed  in 


Fig.  263. 


Nievus  of  Tongue. 


Fig.  261. 


Large  Nsovus  of  Upper  Lip :  Front  View. 


NEVOID  LIPOMA. 


779 


this  way  a  large  venous  pendulous  nfevus,  as  large  as  two  or  three  flat¬ 
tened  walnuts,  from  the  left  labium  of  a  little  girl  six  years  of  age.  In 
this  case,  I  found  it  most  convenient  to  emplo3’  the  continuous  ligature. 
The  same  means  were  had  recourse  to  in  order  to  extirpate  a  large  naivus 
from  the  labium  of  a  child  three  3^ears  of  age  ;  but  in  this  case  the  disease 
extended  to  the  integuments  of  the  perinmum  and  the  inner  side  of  the 
thigh,  and  was  here  removed  b^^  the  application  of  strong  nitric  acid, 
after  the  larger  growth  had  separated. 

On  the  Extremities^  Neck,  and  Trunk  eveiy  possible  variety"  of  nievus 
occurs.  When  the  disease  is  flat,  consistinor  rather  of  stainiim  of  the 
skill  than  of  an}"  actual  tumor,  it  ma}^  commonl>'  be  treated  successfully 
b}'  the  application  of  the  strong  tincture  of  iodine  ;  or,  should  it  be 
thought  desirable  to  remove  it,  this  may  be  effected  b}’’  rubbing  it  with 
strong  nitric  acid.  If  the  mevus  assume  the  form  of  a  tumor,  it  will 
almost  invariably  be  of  a  venous  character,  and  then  removal  b}^  means 
of  the  ligature  should  be  effected.  If  the  growth  be  round,  the  ordinary 
quadruple  ligature  may  be  emplo^'ed ;  if  flat  or  elongated,  the  longitu¬ 
dinal  continuous  ligature  is  preferable. 

Naevoid  Lipoma. — This  is  a  form  of  nrevus  with  which  I  have  occa- 
sionall}'  met,  but  which  does  not  appear  to  liave  attracted  much  notice, 
although  Xelaton  speaks  of  it,  and  Billroth  sa3’s  that  in  lipoma  he  has 
several  times  seen  'cavernous  dilatation  of  the  veins.  It  is  a  tumor  in 
which  the  njevoid  structure  is  conjoined  with  or  deposited  in  a  cellulo- 
fatty  mass.  Tliis  disease  is  invariabl3’’  seated  upon  the  nates,  back,  or 
thigh.  It  occurs  as  a  smooth,  dough3',  indolent  tumor,  incompressible, 
not  varying  in  size  or  shape,  without  heat,  thrill,  or  pulsation  of  any 
kind,  possibl3^  having  a  few  veins  i-amifying  over  its  surface,  but  no  dis¬ 
tinct  vascular  appearance.  It  is  usuall3*  congenital,  or  lias  been  noticed 
in  earl3'  childhood;  and  it  continues  without  aiy'  very  material  change 
in  shape,  size,  or  appearance,  until  the  inconvenience  or  deformit3"  occa¬ 
sioned  b3’’  it  requires  its  removal.  This  is  best  effected  b3’  the  knife. 
After  removal,  the  tumor  will  be  found  to  be  composed  of  a  cellulo- 
adipose  basis,  having  a  large  number  of  veins  ramifying  through  it,  so 
as  to  constitute  a  distinct  vascular  element,  communicating  with  small 
C3-sts  containing  a  bloody  fluid.  The  tumor  has  occasionall3’' a  tendenc3’' 
to  recur  after  removal.  In  one  case  I  have  operated  three  times  for  the 
removal  of  a  large  growth  of  this  description,  situated  on  the  buttock, 
and  extending  forward  towards  the  perinseum.  The  first  operation  was 
performed  in  1851;  the  second  in  1856;  and  the  patient,  then  eighteen 
3’ears  of  age,  again  presented  himself  in  1863  with  a  recurrence  of  the 
growth  in  an  ulcerated  state,  in  the  cicatrix  of  the  former  operations. 
The  situation  in  which  I  have  seen  such  tumors  occur,  where  the3'  gave 
rise  to  the  most  inconvenience,  and  where  their  removal  has  required  the 
greatest  care,  has  been  the  anterior  part  of  the  thigh,  just  below  Pou- 
part’s  ligament,  close  upon  and  almost  in  connection  with  the  femoral 
vessels.  In  a  case  of  this  description,  which  was  sent  to  me  b3’  Edwards 
of  Antigua,  the  patient,  a  gentleman  of  that  island,  had  suffered  for  some 
years  from  a  chronic  solid  oedema  of  one  of  his  legs,  apparentl3"  depen¬ 
dent  upon  the  pressure  exercised  upon  the  saphena  and  femoral  veins  by 
an  elongated  indolent  tumor  just  below  Poupart’s  ligament,  and  over 
the  course  of  these  vessels.  This  tumor  had  existed  from  childhood,  and 
presented  the  signs  that  have  just  been  given  as  characteristic  of  the 
disease  under  consideration.  It  was  removed  b3"  an  incision  parallel  to 
Poupart’s  ligament,  some  careful  dissection  being  required  to  separate 
it  from  the  femoral  sheath,  more  particularl3^  towards  the  inner  side, 


780 


HEMORRHAGIC  DIATHESIS. 


where  a  prolongation  of  the  tumor  dipped  down  by  the  side  of  the  femoral 
vein  doubtless  compressing  that  vessel,  and  so  disposing  to  the  occur¬ 
rence  of  the  oedema  of  the  limb.  After  removal,  the  tumor  was  found  to 
consist  of  a  mass  of  condensed  cellulo-adipose  tissue,  with  much  vascular 
structure  intermixed,  and  some  small  cysts.  The  oedema  gradually  sub¬ 
sided;  and  when  the  patient  left  England,  about  three  months  after  the 
operation,  the  limb  had  nearly  regained  its  normal  size,  being  but  little 
larger  than  the  sound  one. 


HEMORRHAGIC  DIATHESIS. 

In  connection  with  diseases  of  the  arteries,  it  may  be  stated  that  in 
some  constitutions  it  is  found,  though  fortunately  very  rarely,  that  there 
is  a  great  tendency  to  very  troublesome,  indeed  almost  uncontrollable 
bleeding,  from  trivial  wounds ;  life  being  put  in  jeopardy,  or  even  lost, 
by  the  hemorrhage  resulting  from  the  extraction  of  a  tooth,  the  opening 
of  an  abscess,  lancing  the  gums,  or  some  equally  slight  unimportant 
surgical  procedure.  The  blood  does  not  flow  in  a  jet,  but  continues  to 
trickle  in  an  oozing  stream,  apparently'’  from  the  capillaries  rather  than 
from  the  arteries  of  the  part.  In  these  cases  also  there  is  a  great  tendency'' 
to  inordinate  ecchymosis  from  very  slight  contusion,  the  areolar  tissue 
becoming  rapidly  filled  with  fluid  uncoagulable  blood. 

Causes. — The  Hemorrhagic  Diathesis  appears  to  be  connected  with 
or  dependent  upon  one  of  three  distinct  conditions. 

1.  It  may  be  congenital,  and  not  unfrequently  is  hereditary,  especially” 
in  the  male  line.  In  some  families  the  males  only  have  been  affected, 
and  the  diathesis  has  been  transmitted  in  the  seconder  third  generations 
through  females ;  who,  themselves  being  unaffected  by  it,  have  had  male 
children  who  were  the  subjects  of  the  disease.  A  very  remarkable  genealo¬ 
gical  account  of  such  a  family”  has  been  drawn  up  by”  C.  Heath.  This 
diathesis  occurs  in  persons  otherwise  robust  and  strong,  without  any” 
apparent  derangement  of  health,  or  morbid  condition,  innate  or  acquired, 
to  account  for  it.  In  such  cases  the  family  peculiarity  is  usually  recog¬ 
nized,  and  well  known  to  those  liable  to  it. 

2.  The  hemorrhagic  diathesis  may  occur  in  individuals  from  some 
fault  in  the  solid  constituents  of  the  body.  In  persons  wdio  are  “  out  of 
condition,”  with  soft  and  flabby  texture,  the  tissues  have  lost  their  normal 
contractile  power,  and  are  too  readily  torn  by  external  violence.  In  such 
individuals  slight  blows  may  be  followed  by”  extensive  extravasation,  and 
trivial  wounds  by  abundant  and  continuous  hemorrhage.  The  bleeding 
in  these  cases  appears  to  be  favored  by  the  laxity”  of  fibre  interfering 
with  the  proper  contractility  of  the  divided  vessels. 

3.  The  hemorrhagic  diathesis  may  be  dependent  upon  a  morbid  state 
of  the  blood  itself,  in  consequence  of  which  it  has  lost  its  coagulability”, 
the  fibrine  being  insufficient  in  quantity.  This  is  especially  apt  to  occur 
as  a  consequence  of  diseases  that  produce  a  diffluent  state  of  the  blood, 
such  as  chronic  jaundice,  albuminuria,  scurvy,  &c. 

The  last  two  conditions  are  not  unfrequently  associated  together,  the 
bloodvessels  being  insufficiently  contractile,  and  the  blood  too  poor  in 
fibrine,  when  excessive  hemorrhages  are  apt  to  occur  from  the  most 
trifling  wounds.  In  cases  of  this  kind,  care  must  be  taken  not  to  make 
any”  surgical  wounds  if  they  can  possibly  be  avoided ;  though  it  is  a 
remarkable  fact  that  the  hemorrhagic  tendency  here  described  seems  only 
to  have  been  met  with  after  trivial  injuries  of  the  kind  above  mentioned, 
and  not  to  have  been  encountered  in  any  really  serious  surgical  case. 


/ 


TREATMENT  OF  HEMORRHAGIC  DIATHESIS.  781 

Treatment. — In  the  constitutional  treatment  of  the  diathesis,  little 
can  be  done.  It  has  been  proposed  to  administer  saline  h3'dragogue 
purgatives,  with  the  view  of  inspissating  the  blood.  I  should,  however, 
imagine  that  an  improvement  of  the  general  health,  b}"  the  administration 
of  iron,  and  b}-^  careful  attention  to  food,  exercise,  &c.,  would  be  the 
best  means  of  increasing  the  plasticit}-  of  this  fluid.  In  the  event  of  the 
occurrence  of  continuous  bleeding,  the  emplo3’ment  of  pressure,  the  appli¬ 
cation  of  the  actual  cauteiy,  or  the  use  of  the  perchloride  of  iron,  will 
constitute  the  best  means  of  arresting  the  hemorrhage.  In  some  cases 
Middeldorpfs  galvanic  cauteiy  ecraseur  ma}’  be  advantageously"  substi¬ 
tuted  for  the  knife,  when  it  is  desirable  to  remove  parts  in  persons  who 
are  subjects  of  this  diathesis.  By"  this  means,  the  smaller  amputations, 
as  of  the  Angers  or  toes,  the  excision  of  small  tumors  or  the  opening  up 
of  sinuses,  may  be  performed,  without  danger  of  hemorrhage. 


END  OF  VOL.  I. 


/V 


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*  !»■  I:  .•  •  •■^*  /■  ^ 

>^*nJalA'‘y  •■•'  '  -' '4^^C  •'■  ■*  a'  />•  .‘■-^’'r 


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||■■‘^  J  >Ja  )^K/  .v^r't 

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ORiaiNAL  COMMUNICATIONS 


full  of  varied  and  important  matter,  of  great  interest  to  all  practitioners.  Thus,  during 
1874,  articles  have  appeared  in  its  pages  from  nearly  one  hundred  gentlemen  of  the 
highest  standing  in  the  profession  throughout  the  United  States.* 

Following  this  is  the  ‘‘Review  Departaient,”  containing  extended  and  impartial 
reviews  of  all  important  new  works,  together  with  numerous  elaborate  “Analytical 
AND  Bibliographical  Notices”  of  nearly  all  the  medical  publications  of  the  day. 

This  is  followed  by  the  “Quarterly  Summary  of  Improvements  and  Discoveries 
IN  the  Medical  Sciences,”  classified  and  arranged  under  different  heads,  presenting 
a  very  complete  digest  of  all  that  is  new  and  interesting  to  the  physician,  abroad  as 
well  as  at  home. 

Thus,  during  the  year  1874,  the  “Journal”  furnished  to  its  subscribers  85  Orig¬ 
inal  Communications,  113  Reviews  and  Bibliographical  Notices,  and  305  articles  in 
the  Quarterly  Summaries,  making  a  total  of  about  Five  Hundred  articles  emanating 
Irom  the  best  professional  minds  in  America  and  Europe. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  “Journal”  are 
successful,  is  showm  by  the  position  accorded  to  it  in  both  America  and  Europe  as  a 
national  exponent  of  medical  progress: — 


America  continues  to  take  a  great  place  in  this 
class  of  journals  (quarterlies),  at  the  head  of  which 
tLe  great  work  of  Dr.  Hays,  the  Amtrican  Journal 
oj  the  Medical  Sciences,  still  holds  its  ground,  as  our 
quotations  have  often  proved. — Dublin  Med.  Press 
and  Circular,  Jan.  31,  1872. 

Of  English  periodicals  the  Lancet,  and  of  American 
the  Am.  Journal  of  the  Medical  Sciences,  are  to  be 
regarded  as  necessities  to  the  reading  practitioner. — 
N  Y.  Medical  Gazette,  Jan.  7,  1871. 

The  American  Journal  of  the  Medical  Sciences 
yields  to  none  in  the  amount  of  original  and  bor¬ 


rowed  matter  it  contains,  and  has  established  for 
itself  a  reputation  in  every  country  where  medicine 
is  cultivated  as  a  science. — Brit,  and  For.  Med.-Ghi- 
rurg.  Review,  April,  1871. 

This,  if  not  the  best,  is  one  of  the  best-conducted 
medical  quarterlies  in  the  English  language,  and  the 
present  number  is  not  by  any  means  inferior  to  its 
predecessors. — London  Lancet,  Aug.  23,  1873. 

Almost  the  only  one  that  circulates  everywhere, 
all  over  the  Union  and  in  Europe. — Loridon  Medical 
Times,  Sept.  5,  1868. 


And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Pub¬ 
lisher  in  the  Vienna  Exhibition  in  1873. 

The  subscription  price  of  the  “American  Journal  of  the  Medical  Sciences”  has 
never  been  raised  during  its  long  career.  It  is  still  Five  Dollars  per  annum  ;  and 
when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  “Medical  News  and 
Library,”  making  in  all  about  1500  large  octavo  pages  per  annum,  free  of  postage. 


IL 


THE  MEDICAL  NEWS  AND  LIBRARY 

is  a  monthly  periodical  of  Thirty-two  large  octavo  pages,  making  384  pages  per 
annum.  Its  “News  Department”  presents  the  current  information  of  the  day,  with 
Clinical  Lectures  and  Hospital  Gleanings ;  while  the  “  Library  Department”  is  de¬ 
voted  to  publishing  standard  works  on  the  various  branches  of  medical  science,  paged 

*  Communications  are  invited  from  gentlemen  in  all  parts  of  the  country.  Elaborate  articles  inserted 
by  the  Editor  are  paid  for  by  the  Publisher. 


Henry  C.  Lea^s  Publications — {Am.  Journ.  Med.  Science.^). 


3 


separately,  so  that  they  can  be  removed  and  bound  on  completion.  In  this  manner 
subscribers  have  received,  without  expense,  such  works  as  “Watson's  Peactice,” 
“  Todd  and  Bowman’s  Physiology.”  “  West  on  Children,”  “  Malgaigne’s  Sur¬ 
gery,”  tfcc.  &c.  With  Jan.  1875,  was  commenced  the  publication  of  Ur.  William 
Stokes’s  new  work  on  Fever  (see  p.  14),  rendering  this  a  very  desirable  time  for  new 
subscriptions. 

As  stated  above,  the  subscription  price  of  the  “Medical  News  and  Library”  is 
One  Dollar  per  annum  in  advance;  and  it  is  furnished  without  charge  to  all  advance 
paying  subscribers  to  the  “American  Journal  of  the  Medical  Sciences.” 


III. 

THE  MONTHLY  ABSTRACT  OF  MEDICAL  SCIENCE. 

The  publication  in  England  of  Banking’s  “  Half-Yearly  Abstract  of  the  Medi¬ 
cal  Sciences”  having  ceased  with  the  volume  for  January.  1874,  its  place  has  been 
supplied  in  this  country  by  a  monthly  “  Abstract”  containing  forty-eight  large  octavo 
pages  each  month,  thus  furnishing  in  the  course  of  the  year  about  six  hundred  pages, 
the  same  amount  of  matter  as  heretofore  embraced  in  the  Half-Yearly  Abstract. 
As  the  discontinuance  of  the  ‘•Ranking”  arose  from  the  multiplication  of  journals 
appearing  more  frequently  and  presenting  the  same  character  of  material,  it  has  been 
thought  that  this  plan  of  monthly  issues  will  better  meet  the  wants  of  subscribers, 
who  will  thus  receive  earlier  intelligence  of  the  improvements  and  discoveries  in  the 
medical  sciences.  The  aim  of  the  Monthly  Abstr.\ct  will  be  to  present  a  careful 
condensation  of  all  that  is  new  and  important  in  the  medical  journalism  of  the  world, 
and  all  the  prominent  professional  periodicals  of  both  hemispheres  will  be  at  the  dis¬ 
posal  of  the  Editors. 

Subscribers  desiring  to  bind  the  Abstract  will  receive,  on  application  at  the  end 
of  each  year,  a  cloth  cover,  gilt  lettered,  for  the  purpose,  or  it  will  be  sent  free  by 
mail  on  receipt  of  the  postage,  which,  under  existing  laws,  will  be  six  cents. 

The  subscription  to  the  “  Monthly  Abstract,”  free  of  postage,  is  Two  Dollars 
AND  A  Half  a  vear,  in  advance. 

4/  ^ 

As  stated  above,  however,  it  will  be  supplied  in  conjunction  with  the  “American 
Journal  of  the  Medican  Sciences”  and  the  “Medical  News  and  Library,”  making 
in  all  about  ’J'wenty-one  Hundred  pages  per  annum,  the  whole  free  of  postage,  for 
Six  Dollars  a  year,  in  advance. 

The  first  volume  of  the  “  Monthly  Abstract,”  from  July  to  December,  1874,  can 
be  had  by  those  who  desire  to  have  complete  sets,  if  early  application  be  made,  for 
31  50,  forming  a  handsome  octavo  volume  of  300  pages,  cloth. 

In  this  effort  to  bring  so  large  an  amount  of  practical  information  within  the  reach 
of  every  member  of  the  profession,  the  publisher  confidently  anticipates  the  friendly 
aid  of  ail  who  are  interested  in  the  dissemination  of  sound  medical  literature.  He 
trusts,  especially,  that  the  subscribers  to  the  “American  Medical  Journal”  will  call 
the  attention  of  their  acquaintances  to  the  advantages  thus  offered,  and  that  he  will 
be  sustained  in  the  endeavor  to  permanently  establish  medical  periodical  literature 
on  a  footing  of  cheapness  never  heretofore  attempted. 

PREMIUM  FOR  NEW  SUBSCRIBERS  TO  THE  “JOURNAL.” 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1875,  one  of 
which  must  be  for  a  new  subscriber,  will  receive  as  a  premium,  free  by  mail,  a  copy  of 
“Flint’s  Essays  on  Conservative  Medicine”  (for  advertisement  of  which  see  p.  15), 
or  of  “Sturges’s  Clinical  Medicine”  (see  p.  14),  or  of  the  new  ediiion  of  “Swayne’s 
Obstetric  Aphorisms”  (see  p.  24),  or  of  “Tanner’s  Clinical  Manual”  (see  p.  .5), 
or  of  “Chambers’s  Restorative  Medicine”  (see  p.  16),  or  of  “West  on  Nervous 
Disorders  of  Children”  (see  page  21). 

Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1875,  as  the  constant  increase  in  the  subscription  list 
almost  always  exhausts  the  quantity  printed  shortly  after  publication. 

The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  the  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
“Journal”  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  in  registered 
letters.  Address, 

HENRY  C.  LEA, 

Nos.  706  and  708  Sansom  St.,  Philadelphia,  Pa. 


4 


Henry  C.  Lea’s  Publications — {Dictionaries) 


JJUXGLISON  {ROBLEY),  M.D., 

Late  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philaddphia. 

MEDICAL  LEXICON;  A  Dictionary  of  Medical  Science:  Con¬ 
taining  a  concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry,  htotices  of  Climate  and  of  Mineral  Waters ;  Formulae  for 
Officinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes ;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.  A  New  Edition.  Thoroughly  Revised,  and  very  greatly  Mod¬ 
ified  and  Augmented.  By  Richard  J.  Dunglisox,  M.D.  In  one  very  large  and  hand- 
some  royal  octavo  volume  of  over  1100  pages.  Cloth,  $6  50  ;  leather,  raised  bands,  $7  50. 
{Just  Iss%ied.'^ 


The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a  condensed  view  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.  Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en¬ 
viable  reputation.  During  the  ten  years  which  have  elapsed  since  the  last  revision,  the  additioES 
to  the  nomenclature  of  the  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
of  the  past,  and  up  to  the  time  of  his  death  the  author  labored  assiduously  to  incorporate  every¬ 
thing  requiring  the  attention  of  the  student  or  practitioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre¬ 
vious  revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typographical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorporated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 


A  book  well  known  to  our  readers,  and  of  which  ' 
every  American  ought  to  be  proud.  When  the  learned  , 
author  of  the  work  passed  away,  probably  all  of  us 
feared  lest  the  book  should  not  maintain  its  place  ; 
in  the  advancing  science  who^^e  terms  it  defines.  For¬ 
tunately,  Dr.  Richard  J.  Dunglison,  having  assisted  his  ; 
faiherin  the  revision  of  several  editions  of  the  work, 
and  having  been,  therefore,  trained  in  the  methods  and  ■ 
imbued  with  the  spirit  of  the  book,  has  been  able  to  | 
edit  it.  not  in  the  patchwork  manner  .«o  dear  to  the 
iieart  of  book  editors,  so  repulsive  to  the  taste  of  intel-  , 
ligent  book  readers,  but  to  edit  it  as  a  work  of  the  kind 
should  be  edited — to  carr}-  it  on  steadily,  without  jar 
or  interruption,  along  the  grooves  of  thought  it  has 
travelled  during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and  car¬ 
ried  through,  it  is  only  necessary  to  state  that  more 
than  six  thousand  new  subjects  have  been  added  in  the 
present  edition.  Without  occupying  more  space  with  the 
theme,  we  congratulate  the  editor  on  the  successful 
completion  of  his  labors,  and  hope  he  may  reap  the  well- 
earned  reward  of  profit  and  honor. — Flala.  Med.  Times, 
Jan.  3,  1874. 

About  the  first  book  purchased  by  the  medical  stu-  j 
<dent  is  the  Medical  Dictionary.  The  lexicon  explana-  ! 
tory  of  technical  terms  is  simply  a  sine  qua  non.  In  a 
science  so  extem^ive,  and  with  such  collaterals  as  medi¬ 
cine,  it  is  as  much  a  necessity  also  to  the  practising  ; 
physician.  To  meet  the  wants  of  students  and  most 
physicians,  the  dictionary  must  be  condensed  while  ; 
comprehensive,  and  practical  while  i)erspicacious.  Jt 
was  because  Dunglison’s  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
medicine  was  studied  in  the  English  language.  In  no 
former  revision  have  the  alterations  and  additions  been 
60  great.  More  than  six  thousand  new  subjects  and  terms 
have  been  added.  The  chiefterms  have  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps;  an 
arrangement  which  greatly  facilitates  reference.  We 
may  safely  confirm  the  hope  ventured  by  the  editor 

that  the  work,  which  possesses  for  him  a  filial  as  well 
as  an  individual  interest,  will  be  found  worthy  a  con¬ 
tinuance  of  the  position  so  long  accorded  to  it  as  a 
standard  authority.” — Cincinnati  Clinic,  Jan.  10,  1874. 


IVe  are  glad  to  see  a  new  edition  of  this  invaluable 
work,  and  to  find  that  it  has  been  so  thoroughly  revised, 
and  so  greatly  improved.  The  dictionary,  in  its  pre¬ 
sent  form,  is  a  medical  library  in  itself,  and  one  of 
which  every  physician  should  be  possessed. — N.  Y.  Med. 
Journal,  Feb.  1874. 

With  a  history  of  forty  years  of  unexampled  success 
and  universal  indorsement  hy  the  medical  profession  of 
the  western  continent,  it  would  be  presumption  in  any 
living  medical  American  to  essay  its  review.  No  re¬ 
viewer,  however  able,  can  add  to  its  fame;  no  captious 
critic,  however  cau.<tic,  can  remove  a  single  stone  from 
its  firm  and  enduring  foundation.  It  is  destined,  as  a 
i  colossal  monument,  to  perpetuate  the  solid  and  richly 
deserved  fame  of  Robley  Dunglison  to  coming  genera¬ 
tions.  The  large  additions  made  to  the  vocabulary,  we 
think,  will  be  welcomed  by  the  profession  as  supplying 
the  want  of  a  lexicon  fully  up  with  the  march  of  sci¬ 
ence,  which  has  been  increasingly  felt  for  some  years 
I  past.  The  accentuation  of  terms  is  very  complete,  and, 
as  far  as  we  have  been  able  to  examine  it,  very  excel¬ 
lent.  We  hope  it  may  be  the  means  of  securing  greater 
uniformity  of  pronunciation  among  medical  men. — At¬ 
lanta  Med.  o.nd  Surg.  Jown.,  Feb.  1874. 

It  would  be  mere  waste  of  words  in  us  to  express 
our  admiration  of  a  work  which  is  so  universally 
and  deservedly  appreciated.  The  most  admirable 
work  of  its  kind  in  the  English  language. —  'Glasgow 
Medical  Journal,  January,  1866. 

A  work  to  which  there  is  no  equal  in  the  English 
language. — Edinburgh  Medical  Journal. 

Few  works  of  the  class  exhibit  a  grander  monument 
of  patient  research  and  of  scientific  lore.  The  extent 
of  the  sale  of  this  lexicon  is  sufficient  to  testify  to  its 
asefulness,  and  to  the  great  service  conferred  by  Dr. 
Robley  Dunglison  on  the  profession,  and  indeed  on 
1  others,  by  its  issue. — London  Lancet,  May  13,  1865. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Gazette. 


JJOBLYN  {RICHARD  D.),  M.D. 

A  DICTIONARY  OF  THE  TERMS  HSED  IX  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.  Revised,  with  numerous  additions,  by  Isaac  Hays, 
M.D.,  Editor  of  the  “American  Journal  of  the  Medical  Sciences.”  In  one  large  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  cloth,  $1  50  ;  leather,  $2  00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  etudent’s  table.— /Southern 
.Med,  and  Surg.  Journal. 


Henry  C.  Lea's  Publications — {Manuals). 


5 


^EILL  {JOHN),  M.D.,  and  ^MITH  {FRANCIS  G.),  M.D., 

Prof,  of  the  Institutes  of  Medicine  in  the  Univ.  of  Penna. 

AN  ANALYTICAL  COMPENDIUM  OF  THE  VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12mo. 
volume,  of  about  one  thousand  pages,  with  374  wood  cuts,  cloth,  $4;  strongly  bound  in 


leather,  with  raised  bands,  $4  75. 

The  Compend  of  Drs.  Neilland  Smith  is  incompara¬ 
bly  the  most  valuable  work  of  its  class  ever  published 
In  this  country.  Attempts  have  been  made  in  various 
quarters  to  squeeze  Anatomy,  Physiology,  Surgery, 
the  Practice  of  Medicine,  Obstetrics,  Materia  Medica, 
aud  Chemistry  into  a  single  manual;  but  the  opera¬ 
tion  has  signally  failed  in  the  hands  of  all  up  to  the 
advent  of  “  Neill  and  Smith’s”  volume,  which  is  quite 
a  miracle  of  success.  The  outlines  of  the  whole  are 
admirably  drawn  and  illu.strated,  and  the  authors 
are  eminently  entitled  to  the  grateful  consideration 
of  the  student  of  every  class. — N.  0.  Med.  and  Surg. 
Journal. 

There  are  but  few  students  or  practitioners  of  me¬ 
dicine  unacquainted  with  the  former  editions  of  this 
unassuming  though  highly  instructive  work.  The 
whole  science  of  medicine  appears  to  have  been  sifted, 
B.8  the  gold-bearing  sands  of  El  Dorado,  and  the  pre¬ 


cious  factstreasuredup  in  this  little  volume.  A  com¬ 
plete  portable  library  so  condensed  that  the  student 
may  make  it  his  constant  pocket  companion. —  West¬ 
ern  Lancet. 

In  the  rapid  course  of  lectures,  where  work  for  the 
students  is  heavy,  and  review  necessary  for  an  exa¬ 
mination,  a  compend  is  not  only  valuable,  but  it  is 
almost  a  sine  qua  non.  The  one  before  us  is,  in  most 
of  the  divisions,  the  most  unexceptionable  of  all  books 
of  the  kind  that  we  know  of.  Of  course  it  is  useless 
for  us  to  recommend  it  to  all  last  course  students,  but 
there  is  a  class  to  whom  we  very  sincerely  commend 
tnis  cheap  book  as  worth  its  weight  in  silver — that 
class  is  the  graduates  in  medicine  of  more  than  ten 
years’  standing,  who  have  not  studied  medicine 
since.  They  will  perhaps  find  out  from  it  that  the 
science  is  not  exactly  now  what  it  was  when  they 
left  it  off. — The  Stethoscope. 


JJARTSHORNE  {HENRY),  M.  D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES;  containing 

Handbooks  on  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Practical  Medicine^ 
Surgery,  and  Obstetrics.  Second  Edition,  thoroughly  revised  and  improved.  In  one  large 
royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  477  illustrations  on 
wood.  Cloth,  $4  25;  leather,  $5  00.  {Lately  Issued.) 

The  favor  with  which  this  work  has  been  received  has  stimulated  the  author  in  its  revision  to 
render  it  in  every  way  fitted  to  meet  the  wants  of  the  student,  or  of  the  practitioner  desirous  to 
refresh  his  acquaintance  with  the  various  departments  of  medical  science.  The  va  rious  sections  have 
been  brought  up  to  a  level  with  the  existing  knowledge  of  the  day,  while  preserving  the  condensa¬ 
tion  of  form  by  which  so  vast  an  accumulation  of  facts  have  been  brought  within  so  narrow  a 
compass.  The  series  of  illustrations  has  been  much  improved,  while  by  the  use  of  a  smaller  type 
the  additions  have  been  incorporated  without  increasing  unduly  the  size  of  the  volume. 

The  work  before  us  has  already  successfully  assert¬ 
ed  its  claim  to  the  confidence  and  favor  of  the  profes¬ 
sion  ;  it  but  remains  for  us  to  say  that  in  the  present 
edition  the  whole  work  has  been  fully  overhauled 


and  brought  up  to  the  present  status  of  the  science. — 
Atlanta  Med.  and  Surg.  Journal,  Sept.  1874. 

The  work  is  intended  as  an  aid  to  the  medical  stu¬ 
dent,  and  as  such  appears  to  admirably  fulfil  its  ob¬ 
ject  by  its  excellent  arrangement,  the  full  compilation 
of  facts,  the  perspicuity  and  terseness  of  language. 


and  the  clear  and  instructive  illustrations  in  some 
parts  of  the  work, — American  Journ.  of  Pharmacy, 
Philadelphia,  July,  1874. 

The  volume  will  be  found  useful,  not  only  to  stu¬ 
dents,  but  to  many  others  who  may  desire  to  refresh 
their  memories  with  the  smallest  possible  expendi¬ 
ture  of  time.— A7.  Y.  Med.  Journal,  Sept.  1874. 

The  student  will  find  this  the  most  convenient  and 
useful  book  of  the  kind  on  which  he  can  lay  his 
hand. — Pacific  Med.  and  Surg.  Journ.,  Aug.  1874. 


J  VDLOW  {J.L.),  M.D. 

A  MANUAL  OF  EXAMINATIONS  upon  Anatomy,  Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  cloth,  $3  25  ;  leather,  $3  75. 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
fcble  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


rpANNER  {THOMAS  HAWKES),  M.D.,  ^c. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.  Third  American  from  the  Second  London  Edition.  Revised  and  Enlarged  by 
Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 
&c.  In  one  neat  volume  small  ]2mo.,  of  about  375  pages,  cloth,  $150. 

***  By  reference  to  the  “  Prospectus  of  Journal”  on  page  3,  it  will  be  seen  that  this  work  is 
offered  as  a  premium  for  procuring  new  subscribers  to  the  “American  Journal  op  the  Medical 
Sciences.” 


Taken  as  a  whole,  it  is  the  most  compact  vade  me- 
cum  for  the  use  of  the  advanced  student  and  junior 
practitioner  with  which  we  are  acquainted. — Boston 
Med.  and  Surg.  Journal,  Sept.  22,  1870. 

It  contains  so  much  that  is  valuable,  presented  in 
so  attractive  a  form,  that  it  can  hardly  be  spared 
even  in  the  presence  of  more  full  and  complete  works. 
Its  convenient  size  makes  it  a  valuable  companion 
to  the  country  practitioner,  and  if  constantly  car¬ 
ried  by  him,  would  often  render  him  good  service, 
and  relieve  many  a  doubt  and  perplexity. — Leaven¬ 
worth  Med.  Herald,  July,  1870. 


The  objections  commonly,  and  justly,  urged  against 
the  general  run  of  “compends,”  “conspectuses,”  and 
other  aids  to  indolence,  are  not  applicable  to  this  little 
volume,  which  contains  in  concise  phrase  just  those 
practical  details  that  are  of  most  use  in  daily  diag¬ 
nosis,  but  which  the  young  practitioner  finds  it  difli- 
cult  to  carry  always  in  his  memory  without  some 
quickly  .accessible  means  of  reference.  Altogether, 
the  book  is  one  which  we  can  heartily  commend  to 
those  who  have  not  opportunity  for  extensive  read¬ 
ing,  or  who,  having  read  much,  still  wish  an  occa¬ 
sional  practical  reminder.— A7.  Y.  Med.  Gazette,  Nor. 
10  1870. 


6 


Henry  C.  Lea’s  Publications — {Anatomy). 


flRAY  {HENRY),  F.R.S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London. 

ANATOMY,  DESCRIPTIVE  AND  SURGICAL.  The  Drawings  by 

H.  V.  Carter,  M.  D.,  late  Demonstrator  on  Anatomy  at  St.  George’s  Hospital ;  the  Dissec¬ 
tions  jointly  by  the  Author  and  Dr.  Carter.  A  new  American,  from  the  fifth  enlarged 
and  improved  London  edition.  In  one  magnificent  imperial  octavo  volume,  of  nearly  900 
pages,  with  465  large  and  elaborate  engravings  on  wood.  Price  in  cloth,  $6  00  ;  lea¬ 
ther,  raised  bands,  $7  00.  {Just  Issued.) 

The  author  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  is  cus¬ 
tomary  in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  en  - 
gravings  form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Notwithstanding  the  enlargement  of  this  edition,  it  has  been  kept  at  its  former  very  moderate 
price,  rendering  it  one  of  the  cheapest  works  now  before  the  profession. 

The  illustrations  are  beautifully  executed,  and  ren- !  From  time  to  time,  as  successive  editions  have  ap- 
der  this  work  an  indispensable  adjunct  to  the  library  peared,  we  have  had  much  pleasure  in  expressing 
of  the  surgeon.  This  remark  applies  with  great  force  ;  the  general  judgment  of  the  wonderful  excellence  of 
to  those  surgeons  practising  at  a  distance  from  our  Gray’s  Anatorny. — Cincinnati  Lancet,  3 xilj,  1870. 
large  cities,  as  the  opportunity  of  refreshing  their  Altogether,  it  is  unquestionably  the  most  complete 
memory  by  actual  dissection  is  not  always  attain-  ,  serviceable  text-book  in  anatomy  that  has  ever 
able. — Canada  Med.  Journal,  Aug.  1870.  ^  been  presented  to  the  student,  and  forms  a  striking 

The  work  is  too  well  known  and  appreciated  by  the  ;  contrast  to  the  dry  and  perplexing  volumes  on  the 
profession  to  need  any  comment.  No  medical  man  ;  same  subject  through  which  their  predecessors  strug- 
can  afford  to  be  without  it,  if  its  only  merit  were  to  '  gled  in  days  gone  by. — N.  Y.  Med.  Record,  June  15, 
serve  as  a  reminder  of  that  which  so  soon  becomes  (  1870. 

forgotten,  when  not  called  into  frequent  use,  viz.,  the  |  >pq  commend  Gray’s  Anatomy  to  the  medical  pro¬ 
relations  and  names  of  the  cornplex  organism  of  the  ;  fession  is  almost  as  much  a  work  of  supererogation 
human  body.  The  present  edition  is  much  improved,  i  ^  would  be  to  give  a  favorable  notice  of  the  Bible 
— California  Med.  Gazette,  July,  1870.  i  religious  press.  To  say  that  it  is  the  most 

Gray’s  Anatomy  has  been  so  long  the  standard  of  1  complete  and  conveniently  arranged  text-book  of  its 
perfection  with  every  student  of  anatomy,  that  we  kind,  is  to  repeat  what  each  generation  of  students 
need  do  no  more  than  call  attention  to  the  improve-  '  has  learned  as  a  tradition  of  the  elders,  and  verified 
ment  in  the  present  edition. — Detroit  Review  of  Med.  \  by  personal  experience. — N  Y.  Med.  Gazette,  Dec. 
and  Pharm.,  Aug.  1870.  l  17,  1870. 


OMITH  {HENRY  H.),M.D.,  and  JJORNER  {WILLIAM  E.),  M.D., 

^  Prof  .of  Surgery  in  the  JJniv.  of  Penna.,&c.  Late  Prof,  of  Anatomy  in  the  Univ.  of  Penna.,  Sic. 


AN  ANATOMICAL  ATLAS,  illustrative  of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundred  and 
fifty  beautiful  figures.  $4  50. 


The  plan  of  this  Atlas,  which  renders  it  so  pecu¬ 
liarly  convenient  for  the  student,  and  its  superb  ar- 
tistical  execution,  have  been  already  pointed  out.  We 
must  congratulate  the  student  upon  the  completion 
of  this  Atlas,  as  it  is  the  most  convenient  work  of 


the  kind  that  has  yet  appeared;  and  we  must  add, 
the  very  beautiful  manner  in  which  it  is  “got  up,” 
is  so  creditable  to  the  country  as  to  be  flattering  to 
our  national  pride. — American  MedicalJournal. 


^HARPEY  (  WILLIAM),  M.D.,  and 


VAIN  {JONES  ^  RICHARD). 


HUMAN  ANATOMY.  Revised,  with  Notes  and  Additions,  by  Joseph 

Leidy,  M.D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.  Complete  in  two 
large  octavo  volumes,  of  about  1300  pages,  with  511  illustrations;  cloth,  $6  00. 

The  very  low  price  of  this  standard  work,  and  its  completeness  in  all  departments  of  the  subject, 
should  command  for  it  a  place  in  the  library  of  all  anatomical  students. 


ITODGES  {RICHARD  M.),  M.D., 

Late  Demonstrator  of  Anatomy  in  the  Medical  Department  of  Harvard  University. 

PRACTICAL  DISSECTIONS.  Second  Edition,  thoroaghlj  revised.  In 

one  neat  royal  12mo.  volume,  half-bound,  $2  00. 

The  object  of  this  work  is  to  present  to  the  anatomical  student  a  clear  and  concise  description 
of  that  which  he  is  expected  to  observe  in  an  ordinary  com se  of  dissections.  The  author  has 
endeavored  to  omit  unnecessary  details,  and  to  present  the  subje  jt  in  the  form  which  many  years’ 
experience  has  shown  him  to  be  the  most  convenient  and  intelligible  to  the  student.  In  the 
revision  of  the  present  edition,  he  has  sedulously  labored  to  render  the  volume  more  worthy  of 
the  favor  with  which  it  has  heretofore  been  received. 


HOENER’S  SPECIAL  ANATOMY  AND  HISTOLOGY. 
Eighth  edition,  extensively  revised  and  modified. 


In  2  vols.  8vo.,  of  over  1000  pages,  with  more  than 
300  wood-cuts  ;  cloth,  $6  00. 


Henry  C.  Lea’s  Publications — {Anatomy). 


1 


JJ/^ILSON  [ERASMUS),  F.B.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.  Edited 

by  W.  H.  Gobrecht,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col¬ 
lege  of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In 
one  large  and  handsome  octavo  volume,  of  over  600  large  pages;  cloth,  $4  00;  leather, 
$5  00. 

The  publisher  trusts  that  the  well-earned  reputation  of  this  long-established  favorite  will  be 
znore  than  maintained  by  the  present  edition.  Besides  a  very  thorough  revision  by  the  author,  it 
has  been  most  carefully  examined  by  the  editor,  and  the  efforts  of  both  have  been  directed  to  in¬ 
troducing  everything  which  increased  experience  in  its  use  has  suggested  as  desirable  to  render  it 
a  complete  text-book  for  those  seeking  to  obtain  or  to  renew  an  acquaintance  with  Human  Ana¬ 
tomy.  The  amount  of  additions  which  it  has  thus  received  may  be  estimated  from  the  fact  that 
the  present  edition  contains  over  one-fourth  more  matter  than  the  last,  rendering  a  smaller  type 
and  an  enlarged  page  requisite  to  keep  the  volume  within  a  convenient  size.  The  author  has  not 
only  thus  added  largely  to  the  work,  but  he  has  also  made  alterations  throughout,  wherever  there 
appeared  the  opportunity  of  improving  the  arrangement  or  style,  so  as  to  present  every  fact  in  its 
most  appropriate  manner,  and  to  render  the  whole  as  clear  and  intelligible  as  possible.  The  editoi 
has  exercised  the  utmost  caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  increased 
the  number  of  illustrations,  of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition 
than  in  the  last,  thus  bringing  distinctly  before  the  eye  of  the  student  everything  of  interest  or 
Importance. 


IIEATH  [CHRISTOPHER],  F.R.  G.S., 

Teacher  of  Operative  Surgery  in  University  Oollege,  London. 

PRACTICAL  ANATOMY :  A  Manual  of  Dissections.  From  the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  Keen, 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia. 
In  one  handsome  royal  12mo.  volume  of  578  pages,  with  247  illustrations.  Cloth,  $3  50 ; 


leather,  $4  00.  {LaAely  Ptiblisked.) 

Dr.  Keen,  the  American  editor  of  this  work,  in  his 
preface,  says;  “In  presenting  this  American  edition 
of  ‘Heath’s  Practical  Anatomy,’  I  feel  that  1  have 
been  instrumental  in  supplying  a  want  long  felt  for 
a  real  dissector’s  manual,”  and  this  assertion  of  its 
editor  we  deem  is  fully  justified,  after  an  examina¬ 
tion  of  its  contents,  for  ii  is  really  an  excellent  work. 
Indeed,  we  do  not  hesitate  to  say,  the  best  of  its  class 
with  which  we  are  acquainted  ;  resembling  Wilson 
In  terse  and  clear  description,  excelling  most  of  the 
so-called  practical  anatomical  dissectors  in  the  scope 
of  the  subject  and  practical  selected  matter.  .  .  . 

In  reading  this  work,  one  is  forcibly  impressed  with 
the  great  pains  the  author  takes  to  impress  the  sub¬ 
ject  upon  the  mind  of  the  student.  He’is  full  of  rare 
and  pleasing  little  devices  to  aid  memory  in  main- 


aining  its  hold  upon  the  slippery  slopes  of  anatomy. 
-St.  Louis  Med.  and  Surg.  Journal,  Mar.  10,  1871. 

It  appears  to  us  certain  that,  as  a  guide  in  dissec- 
,ion,  and  as  a  work  containing  facts  of  anatomy  in 
brief  and  easily  understood  form,  this  manual  is 
jomplete.  This  work  contains,  also,  very  perfect 
illustrations  of  parts  which  can  thus  be  more  easily 
inderstood  and  studied;  in  this  respect  it  compares 
avorably  with  works  of  much  greater  pretension. 
Such  manuals  of  anatomy  are  always  favorite  works 
with  medical  students.  We  would  earnestly  recom¬ 
mend  this  one  to  their  attention;  it  has  excellences 
which  make  it  valuable  as  a  guide  in  dissecting,  as 
well  as  in  studying  anatomy. — Buffalo  MedicaA  and 
SurgicalJournal,  Jan.  1871. 


JDELLAMY[E.),  FR.C.S. 

THE  STUDENT’S  GUIDE  TO  SURGICAL  ANATOMY:  A  Text- 

Book  for  Students  preparing  for  their  Pass  Examination.  With  engravings  on  wood.  In 
ono  handsome  royal  12mo.  volume.  Cloth,  $2  25.  {Just  Issued.) 


We  welcome  Mr.  Bellamy’s  work,  as  a  contribu¬ 
tion  to  the  study  of  regional  anatomy,  of  equal  value 
to  the  student  and  the  surgeon.  It  is  written  in  a 
clear  and  concise  style,  and  its  practical  suggestions 
add  largely  to  the  interest  attachiog  to  its  technical 
details  — Chicago  Med.  Examiner,  March  1,  1874. 

We  cordially  congratulate  Mr.  Bellamy  upon  hav¬ 
ing  produced  it — Med.  Times  and  Gaz. 


We  cannot  too  highly  recommend  it. — Student's 
Journal. 

Mr.  Bellamy  has  spared  no  pains  to  produce  a  real¬ 
ly  reliable  student’s  guide  to  surgical  anatomy — one 
which  all  candidates  for  surgical  degrees  may  con¬ 
sult  with  advantage,  and  which  posseses  much  ori¬ 
ginal  matter  — Med.  Press  and  Circular. 


MAG  LISE  [JOSEPH). 

'^^SURGICAL  ANATOMY.  By  Joseph  Maclise,  Surgeon.  In  one 

volume,  very  large  imperial  quarto;  with  68  large  and  splendid  plates,  drawn  in  the  best 
style  and  beautifully  colored,  containing  190  figures,  many  of  them  the  size  of  life;  together 
with  copious  explanatory  letter-press.  Strongly  and  handsomely  bound  in  cloth.  Price 


$14  00. 

We  know  of  no  work  on  surgical  anatomy  which 
#an  compete  with  it. — Lancet. 

The  work  of  Maclise  on  surgical  anatomy  is  of  the 
highest  value.  In  some  respects  it  is  the  best  publi¬ 
cation  of  its  kind  we  have  seen,  and  is  worthy  of  a 
place  in  the  library  of  any  medical  man,  while  the 
student  could  scarcely  make  a  better  investment  than 
this. — The  Western  Journal  of  Medicine  and  Sxergery. 

No  such  lithographic  illustrations  of  surgical  re¬ 


gions  have  hitherto,  we  think,  been  given.  While  i 
the  operator  is  shown  every  vessel  and  nerve  where  , 
in  operation  is  contemplated,  the  exact  anatomist  is  i 
refreshed  by  those  clear  and  distinct  dissections,  } 
which  every  one  must  appreciate  who  has  a  particle  I 
of  enthusiasm.  The  English  medical  press  has  quite 
exhausted  the  words  of  praise,  in  recommending  this 
admirable  treatise. — Boston  Med.  and  Surg.  Journ. 


fJARTSHORNE  [HENRY),  M.D., 

Professor  of  Hygiene,  etc  ,  in  the  Univ.  ofPenna. 

HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.  Second  Edi-, 

tion,  revised.  In  one  royal  12mo.  volume,  with  220  wood-cuts;  cloth,  $1  75.  {Just  Issued.) 


I 


8 


Henry  C.  Lea’s  Publications — {Physiology) 


MARSHALL  {JOHN),  F.  R.  S., 

JJJ.  Professor  of  Surgery  in  University  College, 


London,  &c. 


OUTLINES  OF  PHYSIOLOGY,  HUMAN  AND  COMPARATITF. 

With  Additions  by  Francis  Gurney  Smith,  M.  D.,  Professor  of  the  Institutes  of  Medi¬ 
cine  in  the  University  of  Pennsylvania,  <fec.  With  numerous  illustrations.  In  one  large 
and  handsome  octavo  volume,  of  1026  pages,  cloth,  $6  50  ;  leather,  raised  bands,  $7  60. 


In  fact,  in  every  respect,  Mr.  Marshall  has  present¬ 
ed  us  with  a  most  complete,  reliable,  and  scientific 
work,  and  we  feel  that  it  is  worthy  our  warmest 
commendation. — St.  Louis  Med.  Reporter,  Jan.  1869. 

We  doubt  if  there  is  in  the  English  language  any 
compend  of  physiology  more  useful  to  the  student 
than  this  work. — St.  Louis  Med.  and  Surg.  Journal, 
Jan. 1869. 

It  quite  fulfils,  in  our  opinion,  the  author’s  design 
of  making  it  truly  educational  in  its  character — which 
Is,  perhaps,  the  highest  commendation  that  can  be 
asked. — Am.  Journ.  Med.  Sciences,  Jan.  1869. 

We  may  now  congratulate  him  on  having  com¬ 
pleted  the  latest  as  well  as  the  best  summary  of  mod¬ 
ern  physiological  science,  both  human  and  compara- 


1 


tive,  with  which  we  are  acquainted.  To  speak  ot 
this  work  in  the  terms  ordinarily  used  on  such  occa¬ 
sions  would  not  be  agreeable  to  ourselves,  and  would 
fail  to  do  justice  to  its  author.  To  write  such  a  book 
requires  a  varied  and  wide  range  of  knowledge,  con¬ 
siderable  power  of  analysis,  correct  judgment,  skill 
in  arrangement,  and  conscientious  spirit. — London 
Lancet,  Feb.  22,  1868. 


!  There  arefew,  ifany,  more  accomplished  anatomists 
i  and  physiologists  than  the  distinguished  professor  of 
1  surgery  at  University  College  ;  and  he  has  long  en- 
I  joyed  the  highest  reputation  as  a  teacher  of  physiol- 
I  ogy,  possessing  remarkable  powers  of  clear  exposition 
'  and  graphic  illustration.  We  have  rarely  the  plea- 
[  sure  of  being  able  to  recommend  a  text-book  so  unro- 
I  servedly  asthis. — British  Med.  Journal,  Jan. 25, 1888. 


flARPENTER  {WILLIAM  B.),  M.D.,  F.R.S., 

L/  Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  appli- 

cations  to  Psychology,  Pathology,  Therapeutics,  Hygiene  and  Forensic  Medicine.  A  neT» 
American  from  the  last  and  revised  London  edition.  With  nearly  three  hundred  illustrations. 
Edited,  with  additions,  by  Francis  Gurney  Smith,  M.  D.,  Professor  of  the  Institutes  of 
Medicine  in  the  University  of  Pennsylvania,  &c.  In  one  very  large  and  beautiful  octavo 
volume,  of  about  900  large  pages,  handsomely  printed;  cloth,  $5  50  ;  leather,  raised  bands, 
$6  50. 


With  Dr.  Smith,  we  confidently  believe  “that  the 
present  will  more  than  sustain  the  enviable  reputa¬ 
tion  already  attained  by  former  editions,  of  being 
one  of  the  fullest  and  most  complete  treatises  on  the 
subject  in  the  English  language.’’  We  know  of  none 
from  the  pages  of  which  a  satisfactory  knowledge  of 
the  physiology  of  the  human  organism  can  be  as  well 
obtained,  none  better  adapted  for  the  use  of  such  as 
take  up  the  study  of  physiology  in  its  reference  to 
the  institutes  and  practice  of  medicine. — Am.  Jour. 
Med.  Sciences. 


We  doubt  not  it  is  destined  to  retain  a  strong  hold 
on  public  favor,  and  remain  the  favorite  text-book  in 
our  colleges. — Virginia  Medical  Journal. 

The  above  is  the  title  of  what  is  emphatically  the 
great  work  on  physiology ;  and  we  are  conscious  that 
it  would  be  a  useless,  effort  to  attempt  to  add  any¬ 
thing  to  the  reputation  of  this  invaluable  work,  and 
can  only  say  to  all  with  whom  our  opinion  has  any 
influence,  that  it  is  our  authority. — Atlanta  Med, 
Journal. 


or  THE  SAME  AUTHOR. 

PRINCIPLES  OF  COMPARATIVE  PHYSIOLOGY.  New  Ameri¬ 
can,  from  tbe  Fourth  and  Revised  London  Edition.  In  one  large  and  handsome  octavo 
volume,  with  over  three  hundred  beautiful  illustrations.  Pp.  752.  Cloth,  $5  00. 

As  a  complete  and  condensed  treatise  on  its  extended  and  important  subject,  this  work  becomes 
a  necessity  to  students  of  natural  science,  while  the  very  low  price  at  which  it  is  offered  places  it 
within  the  reach  of  all. 


^IRKES  {WILLIAM  SENHOUSE),  M.D. 

■“■A  MANUAL  OF  PHYSIOLOGY.  Edited  by  W.  Morrant  Baker, 

M.D.,  F.R.C.S.  A  new  American  from  the  eighth  and  improved  London  edition.  With 
about  two  hundred  and  fifty  illustrations.  In  one  large  and  handsome  royal  12mo.  vol¬ 
ume.  Cloth,  $3  25  ;  leather,  $3  75.  {Lately  Issued.) 

Kirkes’  Physiology  has  long  been  known  as  a  concise  and  exceedingly  convenient  text-book, 
presenting  within  a  narrow  compass  all  that  is  important  for  the  student.  The  rapidity  with 
which  successive  editions  have  followed  each  other  in  England  has  enabled  the  editor  to  keep  it 
thoroughly  on  a  level  with  the  changes  and  new  discoveries  made  in  the  science,  and  the  eighth 
edition,  of  which  the  present  is  a  reprint,  has  appeared  so  recently  that  it  may  be  regarded  as 
the  latest  accessible  exposition  of  the  subject. 


On  tbe  whole,  there  is  very  little  in  the  book 
which  either  the  student  or  practitioner  will  not  find 
of  practical  value  and  consistent  with  our  present 
knowledge  of  this  rapidly  changing  science  ;  and  we 
have  no  hesitation  in  expretsing  our  opinion  that 
this  eighth  edition  is  one  of  the  best  handbooks  on 
physiology  which  we  have  in  our  language. — N.  Y. 
Med.  Record,  April  15,  1873. 

This  volume  might  well  be  used  to  replace  many 
)f  the  physiological  text-books  in  use  in  this  coun- 
ry.  It  represents  more  accurately  than  the  works 
•f  Dalton  or  Flint,  the  present  state  of  our  knowl- 
dge  of  most  physiological  questions,  while  it  is 
luch  less  bulky  and  far  more  readable  than  the  lar¬ 


ger  text-books  of  Carpenter  or  Marshall.  The  book 
is  admirably  adapted  to  be  placed  in  the  hands  of 
students. — Boston  Med.  and  Surg.  Journ.,  April  10, 
1873. 

In  its  enlarged  form  it  is,  in  our  opinion,  still  the 
best  book  on  physiology,  most  useful  to  the  student. 
— Phila.  Med.  Times,  Aug.  30,  1873. 

This  is  undoubtedly  the  best  work  for  students  of 
physiology  extant. — Cincinnati  Mtd.  News,  Sept.  ’73. 

It  more  nearly  represents  the  present  condition  of 
physiology  than  any  other  text-book  on  the  subject. — 
Detroit  Rev.  of  Med,  Pharm.,  Nov.  1873. 


Henry  C.  Lea’s  Publications — {Physiology). 


9 


DALTON  {J.  a),  M.D., 

■AJ'  Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  &e. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.  Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.  Sixth  edition,  thoroughly  revised  and  enlarged, 
with  three  hundred  and  sixteen  illustrations  on  wood.  In  one  very  beautiful  octavo  vol¬ 
ume,  of  over  800  pages.  {Nearly  Ready.) 


From  the  F reface  to  the  Sixth  Edition. 


In  the  present  edition  of  this  book,  while  every  part  has  received  a  careful  revision,  the  ori¬ 
ginal  plan  of  arrangement  has  been  changed  only  so  far  as  was  necessary  for  the  introduction  of 
new  material.  Although  the  whole  field  of  physiology  has  been  cultivated,  of  late  years,  with 
unusual  industry  and  success,  perhaps  the  most  important  advances  have  been  made  in  the  two 
departments  of  Physiological  Chemistry  and  the  Nervous  System.  The  number  and  classification 
of  the  proximate  principles,  more  especially,  and  their  relation  to  each  other  in  the  process  of 
nutrition,  have  become,  in  many  respects,  better  understood  than  formerly  ;  though  it  is  evident 
that  this  fundamental  part  of  physiology  is  to  receive,  in  the  future,  modifications  and  additions 
of  the  most  valuable  kind. 

The  additions  and  alterations  in  the  text,  requisite  to  present  concisely  the  growth  of  positive 
physiological  knowledge,  have  resulted  in  spite  of  the  author’s  earnest  efforts  at  condensation, 
in  an  increase  of  fully  fifty  per  cent,  in  the  matter  of  the  work.  A  change,  however,  in  the  ty¬ 
pographical  arrangement  has  accommodated  these  additions  without  undue  enlargement  in  the 
bulk  of  the  volume. 

The  new  chemical  notation  .and  nomenclature  are  introduced  into  the  present  edition,  as  hav¬ 
ing  now  so  generally  taken  the  place  of  the  old,  that  no  confusion  need  result  from  the  change. 
The  centigrade  system  of  measurements  for  length,  volume,  and  weight,  is  also  adopted,  these 
measurements  being  at  present  almost  universally  employed  in  original  physiological  investiga¬ 
tions  and  their  published  accounts.  Temperatures  are  given  in  degrees  of  the  centigrade  s  ale, 
usually  accompanied  by  the  corresponding  degrees  of  Fahrenheit’s  scale,  inclosed  in  brackets. 

New  York,  September,  187.5. 


A  few  notices  of  the  previous  edition  are  subjoined. 


The  fifth  edition  of  this  truly  valuable  work  on 
Human  Physiology  comes  to  us  with  many  valuable 
Improvements  and  additions.  As  a  text-book  of 
physiology  the  work  of  Prof.  Dalton  has  long  been 
well  known  as  one  of  the  best  which  could  be  placed 
in  the  hands  of  student  or  practitioner.  Prof.  Dalton 
has,  in  the  several  editions  of  his  work  heretofore 
published,  labored  to  keep  step  with  the  ad  vancement 
in  science,  and  the  last  edition  shows  by  its  improve¬ 
ments  on  former  ones  that  he  is  determined  to  main¬ 
tain  the  high  standard  of  his  work.  We  predict  for 
the  present  edition  increased  favor,  though  this  work 
has  long  been  the  favorite  standard. — Buffalo  Med. 
and  Surg.  Journal,  April,  1872. 

An  extended  notice  of  a  work  so  generally  and  fa¬ 
vorably  known  as  this  is  unnecessary.  It  is  justly 
regarded  as  one  of  the  most  valuable  text-books  on 
the  subject  in  the  English  language. — St.  Louis  Med. 
Archives,  May,  1872. 

We  know  no  treatise  in  physiology  so  clear,  com¬ 
plete,  well  assimilated,  and  perfectly  digested,  as 
Dalton’s.  He  never  writes  cloudily  or  dubiously,  or 
tn  mere  quotation.  He  assimilates  all  his  material, 
and  from  it  constructs  a  homogeneous  transparent 


irgument,  which  is  always  honest  and  well  informed, 
ind  hides  neither  truth,  ignorance,  nor  doubt,  so  far 
IS  either  belongs  to  the  subject  in  hand. — Brit.  Med. 
Tournal,  March  23,  1872. 

Dr.  Dalton’s  treatise  is  well  known,  and  by  many 
highly  esteemed  in  this  country.  It  is,  indeed,  a  good 
elementary  treatise  on  the  subject  it  professes  to 
teach,  and  may  safely  be  put  into  the  hands  of  Eng¬ 
lish  students.  It  has  one  great  merit — it  is  clear,  and, 
on  the  whole,  admirably  illustrated.  The  part  we 
have  always  esteemed  most  highly  is  that  relating 
to  Embryology.  The  diagrams  given  of  the  various 
stages  of  development  give  a  clearer  view  of  the  sub¬ 
ject  than  do  those  in  general  use  in  this  country  ;  and 
the  text  may  be  said  to  be,  upon  the  whole,  equally 
clear. — London  Med.  Times  and  Gazette,  March  23, 
1872. 

Professor  Dalton  is  regarded  j  ustly  as  the  authority 
in  this  country  on  physiological  subjects,  and  the 
fifth  edition  of  his  valuable  work  fully  j  ustifies  the 
exalted  opinion  the  medical  world  has  of  his  labors. 
This  last  edition  is  greatly  enlarged. — Virginia  Clin¬ 
ical  Record,  April,  1872. 


D^^GLISON  [ROBLEY),  M.D., 

Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOGY.  Eighth  edition.  Thoroughly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.  In  two 
large  and  handsomely  printed  octavo  volumes  of  about  1500  pages,  cloth,  $7  00. 


TEHMANN  {G.  O.). 

PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edi¬ 
tion  by  George  E.  Day,  M.  D.,  F.  R.  S.,  (fee.,  edited  by  R.  E.  Rogers,  M.  D.,  Professor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustration/? 
selected  from  Funke’s  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Com¬ 
plete  in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  two 
hundred  illustrations,  cloth,  $6  00. 


JDF  THE  SAME  AUTHOR. 

MANUAL  OF  CHEMICAL  PHYSIOLOGY.  Translated  from  the 

German,  with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  Introductory 
Essay  on  Vital  Force,  by  Professor  Samuel  Jackson,  M.  D.,  of  the  University  of  Pennsyl¬ 
vania.  With  illustrations  on  wood.  In  one  very  handsome  octavo  volume  of  336  pages, 
cloth,  $2  25. 


10 


Henry  C.  Lea’s  Publications — {Chemistry) 


ATTFIELD  [JOHN),  Ph.D., 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  &c. 

CHEMISTRY,  GENERAL,  MEDICAL,  AND  PHARMACEUTICAL  ; 

including  the  Chemistry  of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principleis 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.  Fifth  Edition,  revised 
by  the  author.  In  one  handsome  royal  12mo.  volume ;  cloth,  $2  75  ;  leather,  $3  25. 
{^Lately  Issued.') 


No  other  American  publication  vith  which  rre  are 
acquainted  covers  the  same  ground, or  does  it  so  -well. 
In  addition  to  an  admirable  expose  of  the  facts  and 
principles  of  general  elementary  chemistry,  the  au¬ 
thor  has.  presented  us  with  a  condensed  mass  of  prac¬ 
tical  matter,  just  such  as  the  medical  student  and 
practitioner  needs. — Cincinnati  Lancet,  Mar  1874. 

We  commend  the  work  heartily  as  one  of  the  best 
text-books  extant  for  the  medical  student. — Detroit 
Rev.  of  Med.  and  Pharm.,  Feb.  1872. 

The  best  work  of  the  kind  in  the  English  language. 
_ TV.  Y.  Psychological  Journal,  Jan.  1872. 

The  work  is  constructed  with  direct  reference  to 
the  wants  of  medical  and  pharmaceutical  students; 
and,  although  an  English  work,  the  points  of  differ¬ 
ence  between  the  British  and  United  States  Pharma¬ 
copoeias  are  indicated,  making  it  as  useful  here  as  in 
England.  Altogether,  the  book  is  one  we  can  heart¬ 
ily  recommend  to  practitioners  as  well  as  students. 
— AT.  Y.  Med.  Journal,  Dec.  1871. 

It  differs  from  other  text-books  in  the  following 
particulars  ;  first,  in  the  exclusion  of  matter  relating 
to  compounds  which,  at  present,  are  only  of  interest 
to  the  scientific  chemist;  secondly,  in  containing  the 
chemistry  of  every  substance  recognized  officially  or 
in  general,  as  a  remedial  agent.  It  will  be  found  a 
most  valuable  book  for  pupils,  a-ssistants,  and  others 


engaged  in  medicine  and  pharmacy,  and  we  heartily 
commend  it  to  our  readers, — Canada  Lancet,  Oct. 
1871. 

When  the  original  English  edition  of  this  work  was 
published,  we  had  occasion  to  express  our  high  ap¬ 
preciation  of  its  worth,  and  also  to  review,  in  con¬ 
siderable  detail,  the  main  features  of  the  book.  As 
the  arrangement  of  subjects,  and  the  main  part  of 
the  text  of  the  present  edition  are  similar  to  the  for¬ 
mer  publication,  it  will  be  needless  for  us  to  go  over 
the  ground  a  second  time  ;  we  may,  however,  call  at¬ 
tention  to  a  marked  advantage  possessed  by  the  Ame¬ 
rican  work — we  allude  to  the  introduction  of  the 
chemistry  of  the  preparations  of  the  United  States 
Pharmacopoeia,  as  well  as  that  relating  to  the  British 
authority.  —  Canadian  Pharmaceutical  Journal, 
Nov.  1871. 

Chemistry  has  borne  the  name  of  being  a  hard  sub¬ 
ject  to  master  by  the  student  of  medicine,  and 
chiefly  because  so  much  of  it  consists  of  compounds 
only  of  interest  to  the  scientific  chemist ;  in  this  work 
such  portions  are  modified  or  altogether  left  out,  and 
in  the  arrangement  of  the  subject  matter  of  the  work, 
practical  utility  is  sought  after,  and  we  think  fully 
attained  Wecommeud  it  for  its  clearness  and  order 
to  both  teacher  and  pupil. — Oregon  Med.  and  Surg. 
Reporter,  Oct.  1871. 


jpOWNES  (GEORGE),  Ph.D. 

A  MANUAL  OP  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.  With  one  hundred  and  ninety-seven  illustrations.  A  new  American,  from  the 
tenth  and  revised  London  edition.  JEdited  by  Robert  Bridges,  M.  D.  In  one  large 
royal  12ino.  volume,  of  about  850  pp.,  cloth,  .<$2  75  ;  leather,  $3  25.  {Lately  Issued.) 

This  work  is  so  well  known  that  it  seems  almost  other  work  that  has  greater  claims  on  the  physician, 
enperfiuous  for  us  to  speak  about  it.  It  has  been  a  pharmaceutist,  or  student,  than  this.  We  cheerfully 
favorite  text-hook  with  medical  students  for  years,  recommend  it  as  the  best  text-hook  on  elementary 
and  its  popularity  has  in  no  respect  diminished,  chemistry,  and  bespeak  for  it  the  careful  attention 
Whenever  we  have  been  consulted  hy  medical  stu-  of  students  of  pharmacy. — Chicago  Pharmacist,  Rng, 
dents,  as  has  frequently  occurred,  what  treatise  on  1869. 
chemistry  they  should  procure,  we  have  always  re- 

commendf>d  Fownes’,  for  we  regarded  it  as  the  best.  Here  is  a  new  edition  which  has  been  long  watched 
There  is  no  work  that  combines  so  many  excellen-  for  hy  eager  teachers  of  chemistry.  In  its  new  garb, 
ces.  It  is  of  convenient  size,  not  prolix,  of  plain  and  under  the  editorship  of  Mr.  Watts,  it  has  resumed 
perspicuous  diction,  contain.s  all  the  most  recent  its  old  place  as  the  most  successful  of  text-books.—- 
discoveries,  and  is  of  moderate  price. — Cincinnati  Indian  Medical  Gazette,  J&n. 

Med.  Repertory,  Aug.  1869.  continue,  as  heretofore,  to  hold  the  first  rank 

Large  additions  have  been  made,  especially  in  the  is  a  text-book  for  students  of  medicine. — Chicago 
department  of  organic  chemistry,  and  we  know  of  no  Med.  Examiner,  Aug.  1869. 


QDLTNG  ( WILLIAM), 

Lecturer  on  Chemistry  at  St.  Bartholomew' s  Hospital,  &c. 

A  COURSE  OF  PRACTICAL  CHEMISTRY,  arranged  for  the  Use 

of  Medical  Students.  With  Illustrations.  From  the  Fourth  and  Revised  London  Edition. 
In  one  neat  royal  12mo.  volume,  cloth,  $2. 


(I  ALLOW  AY  [ROBERT),  F.C.S., 

Prof,  of  Applied  Chemistry  in  the  Royal  College  of  Science  for  Ireland,  &c. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.  Prom  the  Fifth  Lon¬ 
don  Edition.  In  one  neat  royal  12mo.  volume,  with  illustrations;  cloth,  $2  50.  {Jusi 
Issued.) 

The  success  which  has  carried  this  work  through  repeated  editions  in  England,  and  its  adoption 
as  a  text-book  in  several  of  the  leading  institutions  in  this  country,  show  that  the  author  has  suc¬ 
ceeded  in  the  endeavor  to  produce  a  sound  practical  manual  and  book  of  reference  for  the  che¬ 
mical  student. 


Prof.  Galloway’s  hooks  are  deservedly  in  high 
esteem,  and  this  American  reprint  of  the  fifth  edition 
(.1869)  of  his  Manual  of  Qualitative  Analysis,  will  be 
acceptable  to  many  American  students  to  whom  the 
English  edition  is  not  accessible. — Am.  Jour,  of  Sci¬ 
ence  and  Arts,  Sept.  1872. 


We  regard  this  volume  as  a  valuable  addition  to 
the  chemical  text-books,  and  as  particularly  calcu¬ 
lated  to  instruct  the  student  in  analytical  researches 
of  the  inorganic  compounds,  the  important  vegetable 
acids,  and  of  compounds  and  various  secretions  and 
excretions  of  animal  origin. — Am.  Journ.  of  Pharm., 
Sept.  1872. 


Henry  C.  Lea’s  Publications — {Chemistry) 


11 


T>LOXAM  [C.  L.), 

Professor  of  Chemi.<(try  in  King's  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.  From  the  Second  Lon- 

don  Edition.  In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illustra¬ 
tions.  Cloth,  $4  00  ;  leather,  $5  00.  {^Lately  Issued .) 

It  has  been  the  author’s  endeavor  to  produce  a  Treatise  on  Chemistry  sufficiently  comprehen¬ 
sive  for  those  studying  the  science  as  a  branch  of  ^  neral  education,  and  one  which  a  student 
may  use  with  advantage  in  pursuing  his  chemical  stud  s  at  one  of  the  colleges  or  medical  schools. 
The  special  attention  devoted  to  Metallurgy  and  some  other  branches  of  Applied  Chemistry  renders 


the  work  especially  useful  to  those  who  are  beinj 

We  have  ia  this  work  a  complete  and  most  excel¬ 
lent  text-book  for  the  u-e  of  schools,  and  can  heart¬ 
ily  recommend  it  as  such. — Boston  Med.  and  Surg.  ] 
Jortrn.,  May  28,  1S74.  ; 

Of  all  the  numerous  works  upon  elementary  chem-  j 
istry  that  have  been  published  within  the  last  few 
years,  we  can  point  to  none  that,  in  fulness,  accuracy, 
and  simplicity,  can  surpass  this ;  while,  in  the  num¬ 
ber  and  detailed  descriptions  of  experiments,  as  also  ; 
in  the  profuseness  of  its  illustrations,  we  believe  it  | 
stands  above  any  similar  work  published  in  thiscoun-  j 

try . The  statements  made  are  clear  and  con-  ] 

cise.  and  every  step  proved  by  an  abundance  of  ex¬ 
periments,  which  excite  our  admiration  as  much  by 
their  simplicity  as  by  their  direct  conclusiveness. — 
Chicago  Med.  Examiner,  Nov.  Id,  1S73. 

It  is  seldom  that  in  the  same  compass  so  complete 
and  interesting  a  compendium  of  the  leading  facts  of 
chemistry  is  offered. — Druggists'  Circular,  Nov.  T3. 

The  above  is  the  title  of  a  work  which  we  can  most 
conscienrionsly  recommend  to  students  of  chemistry. 
It  is  as  easy  as  a  work  on  chemi-try  could  be  made, 
at  the  same  time  that  it  presents  a  full  account  of  that 
science  as  it  now  stands.  We  have  spoken  of  the 
workasadmirably  adapted  to  the  wants  of  students  ; 
it  is  quite  as  well  suited  to  the  requirements  of  prac¬ 
titioners  who  wi.sh  to  review  their  chemistry,  or  have 
occasion  to  refresh  their  memories  on  any  point  re¬ 
lating  to  it.  In  a  word,  it  is  a  book  to  be  read  by  all 
who  wish  to  know  what  is  the  chemistry  of  the  pre¬ 
sent  day. — American  Practitioner,  Nov.  IS73. 

Among  the  various  works  upon  general  chemistry 
issued,  we  know  of  none  that  will  supply  the  average 
wants  of  the  student  or  teacher  better  than  this. — 
Indiana  Jour n.  of  Med.,  Nov.  1873. 

We  cordially  welcome  this  American  reprint  of  a  j 
work  which  has  already  won  for  itself  so  substantial 
a  reputation  in  England.  Professor  Bloxam  has  con-  , 
densed  into  a  wonderfully  small  com  ass  all  the  im-  > 
portant  principles  and  facts  of  chemical  science. 
Thoroughly  imbued  with  an  enthusiastic  love  for  the 
science  he  expound.*,  he  has  stripped  it  of  all  need-  i 
less  technicalities,  and  rounded  out  its  hard  outlines  j 
by  a  fulness  of  illu.stration  that  cannot  fail  to  attract  j 
and  delight  the  student.  The  details  of  illustrative  ‘ 


;  educated  for  employment  in  manufacture. 

experiment  have  been  worked  up  with  especial  care, 
and  many  of  the  experiments  described  are  both  new 
and  striking. — Detroit  Rev.  of  Med.  and  Pharrn., 
Nov.  1873. 

One  of  the  best  text-books  of  chemistry  yet  pub¬ 
lished. — Chicago  Med  Journ.,  Nov.  lS7c. 

This  is  an  excellent  work,  well  adapted  for  the  be¬ 
ginner  and  the  advanced  student  of  chemistry. — Arn. 
■lonm.  of  Pharni  ,  Nov.  1873. 

Probably  the  most  valuable,  and  at  the  same  time 
practical,  text-book  on  general  chemistry  e.xtant  in 
our  language. — Kansas  City  Med.  Journ.,  Dec.  1873. 

Prof.  Bloxam  pos.sesses  pre-eminently  the  inestima¬ 
ble  gift  of  perspicuity.  It  is  a  pleasure  to  read  his 
books,  for  he  is  capable  of  making  very  plain  what 
other  authors  frequently  have  left  very  obscure. — 
Va.  Clinical  Record,  Nov.  1873. 

It  would  be  difficult  for  a  practical  chemist  and 

■  teacher  to  find  any  material  fault  with  this  most  ad- 
j  mirable  treatise.  The  author  has  given  us  almost  a 
I  cyclopedia  within  the  limits  of  a  convenient  volume, 
,  and  has  done  so  without  penning  the  useless  para- 
I  graphs  too  commonly  making  up  a  great  part  of  the 

bulk  of  many  cumbrous  works.  The  progressive  sci- 

■  entist  is  not  disappointed  when  he  looks  for  the  record 
I  of  new  and  valuable  processes  and  discoveries,  while 

the  cautious  conservative  does  not  find  its  pages  mo¬ 
nopolized  by  uncertain  theories  and  speculations.  A 
peculiar  point  of  excellence  is  the  crystallized  form  of 
expression  in  which  great  truths  are  expressed  in 
very  short  paragraphs.  -One  is  surprised  at  the  brief 
,  space  allotted  to  an  important  topic,  and  yet,  after 
reading  it,  he  feels  that  little,  if  any  more,  should 
have  been  said.  Altogether,  it  is  seldom  yon  see  a 
text-book  so  nearly  faultless.— (Jtncmziaf'i  Lancet, 
Nov.  1873. 

Professor  Bloxam  has  given  us  a  most  excellent 
and  useful  practical  treatise.  His  666  pages  are 
crowded  with  facts  and  experiments,  nearly  all  well 
chosen,  and  many  quite  new,  even  to  >cientific  men. 

.  .  .  It  is  astonishing  how  much  information  he  often 

conveys  in  a  few  paragraphs.  We  might  quote  fifty 
instances  of  this. — Chemical  News. 


T^OHLER  AND  FITTIG. 

"  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated  with  Ad- 

ditions  from  the  Eighth  German  Edition.  By  Iba  Remsen,  M.D.,  Ph.D.,  Professor  of 
Chemistry  and  Physics  in  Williams  College,  Mass.  In  one  handsome  volume,  royal  12mo. 
of  550  pp. ,  cloth,  $3. 

As  the  numerous  editions  of  the  original  attest,  this  work  is  the  leading  text-book  and  standard 
authority  throughout  Germany  on  its  important  and  intricate  subject — a  position  won  for  it  by 
the  clearness  and  conciseness  which  are  its  distinguishing  characteristics.  The  translation  has 
been  executed  with  the  approbation  of  Profs.  Wohler  and  Fittig,  and  numerous  additions  and 
alterations  have  been  introduced,  so  as  to  render  it  in  every  respect  on  a  level  with  the  most 
advanced  condition  of  the  science. 

DOWJ/AN  (JOHN  E.),M.  D. 

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.  Edited 

by  C.  L.  Bloxam,  Professor  of  Practical  Chemistry  in  King’s  College,  London.  Sixth 
American,  from  the  fourth  and  revised  English  Edition.  In  one  neat  volume,  royal  12mo., 
pp.  351,  with  numerous  illustrations,  cloth,  S2  25. 

THE  SAME  AUTHOR.  {Lately  Issued.)  - 

INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.  Sixth  American,  from  the  sixth  and  revised  London  edition.  With  numer* 
ous  illustrations.  In  one  neat  vol.,  royal  12mo.,  cloth,  $2  25. 


KNAPP’S  TECHNOLOGY  ;  or  Chemistry  Applied  to 
the  Arts,  aad  to  Manufactures.  With  American 
additioas,  by  Prof.  Waltsx  R.  Johnson,  In  two 


very  handsome  octavo  volnmes,  with  500  wood 
engravings,  cloth,  $6  00. 


12  Henry  0.  Lea’s  Publications — {Mat.Med.OMd  Therapeutics) 


pARRlSH  [ED  WARD), 

Late  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.  Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  and 
Prescriptions.  Fourth  Edition,  thoroughly  revised,  by  Thomas  S.  Wiegand.  In  one 
handsome  octavo  volume  of  977  pages,  with  280  illustrations ;  cloth,  $5  50 ;  leather,  $6  50. 
iJnst  Issued.) 


The  delay  in  the  appearance  of  the  new  U.  S.  Pharmacopoeia,  and  the  sudden  death  of  the  au 
thor,  have  postponed  the  preparation  of  this  new  edition  beyond  the  period  expected.  The  note 
and  memoranda  left  by  Mr.  Parrish  have  been  placed  in  the  hands  of  the  editor,  Mr.  Wiegand, 
who  has  labored  assiduously  to  embody  in  the  work  all  the  improvements  of  pharmaceutical  sci¬ 
ence  which  have  been  introduced  during  he  last  ten  years.  It  is  therefore  hoped  that  the  new 
edition  will  fully  maintain  the  reputation  which  the  volume  has  heretofore  enjoyed  as  a  standard 


text-book  and  work  of  reference  for  all  engaged 

Of  Or.  Parrish’s  great  Tvork  on  pharmacy  it  only 
remains  to  be  said  that  the  editor  has  accomplished 
his  TTork  so  -n-ell  as  to  maintain,  in  this  fourth  edi¬ 
tion,  the  high  standard  of  excellence  which  it  bad 
attained  in  previous  editions,  under  the  editorship  of 
its  accomplished  author.  This  has  not  been  accom 
plished  without  much  labor,  and  many  additions  and 
improvements,  involving  changes  in  the  arrangement 
of  the  several  parts  of  the  work,  and  the  addition  of 
much  new  matter.  With  the  modifications  thus  ef¬ 
fected  it  constitutes,  as  now  presented,  a  compendium 
of  the  science  and  art  indispensable  to  the  pharma-  1 
cist,  and  of  the  utmost  value  to  every  practitioner 
of  medicine  desirous  of  familiarizing  himself  with  ' 
the  pharmaceutical  preparation  of  the  articles  which  : 
he  prescribes  for  his  patients. — Chicago  Med.  Journ., 
July,  1874. 

The  work  is  eminently  practical,  and  has  the  rare 
merit  of  being  readable  and  interesting,  while  it  pre-  j 
serves  a  strictly  scientific  character.  The  whole  work 
reflects  the  greatest  credit  on  author,  editor,  and  pub¬ 
lisher  It  will  convey  some  idea  oft  he  liberality  which  j 
has  been  bestowed  upon  its  production  when  we  men-  j 
tion  that  there  are  no  less  than  280  carefully  executed  j 
illustrations.  In  conclusion,  we  heartily  recommend  j 
the  work,  not  only  to  pharmacists,  but  also  to  the 
multitude  of  medical  practitioners  who  are  obliged  ! 
to  compound  their  own  medicines.  It  will  ever  hold 


in  the  preparation  and  dispensing  of  medicines. 

an  honored  place  on  our  own  bookshelves. — Dublin 
Med.  Press  and  Circular,  Aug.  12,  1874. 

We  expressed  our  opinion  of  a  former  edition  in 
terms  of  unqualified  praise,  and  we  are  in  no  mood 
to  detract  from  that  opinion  in  reference  to  the  pre¬ 
sent  edition,  the  preparation  of  which  has  fallen  into 
competent  hands.  It  is  a  book  with  which  no  pharma¬ 
cist  can  dispense,  and  from  which  no  physician  can 
fail  to  derive  much  information  of  value  to  him  in 
practice. — Pacific  Med.  andSrirg.  Journ.,  June,  ’74. 

With  these  few  remarks  we  heartily  commend  the 
work,  and  have  no  doubt  that  it  will  maintain  its 
old  reputation  as  a  text-book  for  the  student,  and  a 
work  of  reference  for  the  more  experienced  physi¬ 
cian  and  pharmacist . —  Chicago  Med.  Examiner, 
June  15,  1874. 

Perhaps  one,  if  not  the  most  important  book  upon 
pharmacy  which  has  appeared  in  the  English  lan¬ 
guage  has  emanated  from  the  transatlantic  press. 
“Parrish's  Pharmacy”  is  a  well-known  work  on  this 
side  of  the  water,  and  the  fact  shows  us  that  a  really 
useful  work  never  becomes  merely  local  in  its  fame. 
Thanks  to  the  judicious  editing  of  Mr.  Wiegand,  the 
posthumous  edition  of  “Parrish”  has  been  saved  to 
the  public  with  all  the  mature  experience  of  its  au¬ 
thor,  and  perhaps  none  the  worse  for  a  dash  of  new 
blood. — Lond.  Pharrn.  Journal,  Oct.  17,  1874. 


OT/LLE  [ALFRED),  M.D., 

Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Fourth  edit.,  revised  and  enlarged.  In  two  large  and  handsome  8vo.  vols.  of  about  2000 
pages.  Cloth,  $10;  leather,  $12.  {Now  Ready.) 

The  care  bestowed  by  the  author  on  the  revision  of  this  edition  has  kept  the  work  out  of  th® 
market  for  nearly  two  years,  and  has  increased  its  size  about  two  hundred  and  fifty  pages.  Not* 
Avithstanding  this  enlargement,  the  price  has  been  kept  at  the  former  very  moderate  rate.  A  few 
notices  of  former  editions  are  subjoined. 


Dr.  Stille’s  splendid  work  on  therapeutics  and  ma¬ 
teria  medica. — London  Med.  Times,  April  8,  1865. 

Dr.  Still6  stands  to-day  one  of  the  best  and  most 
honored  representatives  at  home  and  abroad,  of  Ame¬ 
rican  medicine ;  and  these  volumes,  a  library  in  them¬ 
selves,  a  treasure-house  for  every  studious  physician, 
assure  his  fame  even  had  he  done  nothing  more. — The 
Western  Journal  of  Medicine,  Dec.  1868. 

We  regard  this  work  as  the  best  one  on  Materia 
Medica  in  the  English  language,  and  as  such  it  de¬ 
serves  the  favor  it  has  received. — Am.  Journ.  Medi¬ 
cal  Sciences,  July  1868. 

We  need  not  dwell  on  the  merits  of  the  third  edition 
of  this  magnificently  conceived  work.  It  is  the  work 
on  Materia  Medica,  in  which  Therapeutics  are  prima¬ 
rily  considered — the  mere  natural  history  of  drug.s 
being  briefly  disposed  of.  To  medical  practitioners 
this  is  a  very  valuable  conception.  It  is  wonderful 
how  much  of  the  riches  of  the  literature  of  Materia 
Medica  has  been  condensed  into  this  book.  The  refer¬ 
ences  alone  would  make  it  worth  possessing.  But  it 
is  not  a  mere  compilation.  The  winter  exercises  a 
good  judgment  of  his  own  on  the  great  doctrines  and 
points  of  Therapeutics  For  purposes  of  practice, 
Still6’s  book  is  almost  unique  as  a  repertory  of  in¬ 
formation,  empirical  and  scientific,  on  the  actions  and 
uses  of  medicines. — London  Lancet,  Oct.  31,  1868. 

Through  the  former  editions,  the  professional  world 
is  well  acquainted  with  this  work.  At  home  and 


I  abroad  its  reputation  as  a  standard  treatise  on  Materia 
1  Medica  is  securely  established.  It  is  second  to  no 
!  work  on  the  subject  in  the  English  tongue,  and,  in- 
!  deed,  is  decidedly  superior,  in  some  respects,  to  any 
I  other. — Pacific  Med.  and  Surg  Journal,  July,  1868. 

1  Still6’s  Therapeutics  is  incomparably  the  best  work 
i  on  the  subject. — N.  Y.  Med.  Gazette,  Sept.  26,  1868. 

]  Dr.  Stilly’s  work  is  becoming  the  best  known  of  any 
'  of  our  treatises  on  Materia  Medica.  .  .  .  One  of  the 
most  valuable  works  in  the  language  on  the  snbjectt 
of  which  it  treats. — N.  F.  Med.  Journal,  Oct.  1868. 

The  rapid  exhaustion  of  two  editions  of  Prof.  Still6’» 
scholarly  work,  and  the  consequent  necessity  for  a 
third  edition,  is  suflicient  evidence  of  the  high  esti¬ 
mate  placed  upon  it  by  the  profession.  It  is  no  exag¬ 
geration  to  say  that  there  is  no  superior  work  upon 
the  subject  in  the  English  language.  The  present 
edition  is  fully  up  to  the  most  recent  advance  in  the 
science  and  art  of  therapeutics. — Leavenworth  Medi¬ 
cal  Herald,  Aug.  1868. 

The  work  of  Prof.  Still6  has  rapidly  taken  a  high 
place  in  professional  esteem,  and  to  say  that  a  third 
edition  is  demanded  and  now  appears  before  ns,  suffi¬ 
ciently  attests  the  firm  position  this  treatise  has  made 
for  itself.  As  a  work  of  great  research,  and  scholar¬ 
ship,  it  is  safe  to  say  we  have  nothing  superior.  It  is 
exceedingly  full,  and  the  busy  practitioner  will  find 
ample  suggestions  upon  almost  every  important  point 
of  therapeutics. — Cincinnati  Lancet,  Aug.  1868. 


Henry  C.  Lea’s  Publications — {Mat.  Med.  and  Therapeutics).  13 


QRIFFITH  {ROBERT  E.),  M.D. 

A  UXIYERSAL  FORMULARY,  Containing  the  Methods  of  Prepar¬ 
ing  and  Administering  OflBcinal  and  other  Medicines.  The  whole  adapted  to  Physician?  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  bj  John  M. 
Maisch,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large 
and  handsome  octavo  volume  of  about  800  pages,  cloth,  $4  50;  leather,  $5  50.  {Just  Issued.) 

This  work  has  long  been  known  for  the  vast  amount  of  information  which  it  presents  in  a  con¬ 
densed  form,  arranged  for  easy  reference.  The  new  edition  has  received  the  most  careful  revi¬ 
sion  at  the  competent  hands  of  Professor  Maisch,  who  has  brought  the  whole  up  to  the  standard  of 
the  most  recent  authorities.  More  than  eighty  new  headings  of  remedies  have  been  introduced, 
the  entire  work  has  been  thoroughly  remodelled,  and  whatever  has  seemed  to  be  obsolete  has  been 
omitted.  As  a  comparative  view  of  the  United  States,  the  British,  the  German,  and  the  French 
Pharmacopoeias,  together  with  an  immense  amount  of  unoflBcinal  formulas,  it  affords  to  the  prac¬ 
titioner  and  pharmaceutist  an  aid  in  their  daily  avocations  not  to  be  found  elsewhere,  while  three 
indexes,  one  of  ‘‘Diseases  and  their  Remedies,”  one  of  Pharmaceutical  Names,  and  a  General 
Index,  afford  an  easy  key  to  the  alphabetical  arrangement  adopted  in  the  text. 


The  young  practitioner  will  find  the  work  invalu¬ 
able  in  suggesting  eligible  modes  of  administering 
many  remedies. — Ara.  Journ.  of  Pharrn.,  Feb.  1874. 

Our  copy  of  Griffith’s  Formulary,  after  long  use, 
first  in  the  dispensing  shop,  and  afterwards  in  our 
medical  practice,  had  gradually  fallen  behind  in  the 
onward  march  of  materia  medica,  pharmacy,  and 
therapeutics,  until  we  had  ceased  to  consnlt’itas  a 
daily  book  of  reference.  So  completely  has  Prof. 
JIaisch  reformed,  remodelled,  and  rejuvenated  it  in 
the  new  edition,  we  shall  gladly  welcome  it  back  to 
our  table  again  beside  Dunglison,  Webster,  and  Wood 
&  Bache.  The  publisher  could  not  have  been  more 
fortunate  in  the  selection  of  an  editor.  Prof.  Maisch 
is  eminently  the  man  for  the  work,  and  he  has  done 
it  thoroughly  and  ably.  To  enumerate  the  altera¬ 
tions,  amendments,  and  additions  would  be  an  end¬ 
less  task ;  everywhere  we  are  greeted  with  the  evi¬ 
dences  of  his  labor.  Following  the  Formulary,  is  an 
addendum  of  useful  Recipes,  Dietetic  Preparations, 
List  of  Incompatibles,  Posological  table,  table  of 
Pharmaceutical  Names,  Officinal  Preparations  and 
Directions.  Poisons.  Antidotes  and  Treatment,  and 
copious  indices,  which  afford  ready  access  to  all  parts 
of  the  work.  We  unhesitatingly  commend  the  book 
as  being  the  best  of  its  kind,  within  our  knowledge. 
— Atlanta  Med.  and  Surg.  Journ.,  Feb.  1S74. 


To  the  druggist  a  good  formulary  is  simply  indis¬ 
pensable,  and  perhaps  no  formulary  has  been  more 
extensively  used  than  the  well-known  work  before 
us.  Many  physicians  have  to  officiate,  also,  as  drug¬ 
gists.  This  is  true  especially  of  the  country  physi¬ 
cian.  and  a  work  which  shall  teach  him  the  means 
by  which  to  administer  or  combine  his  remedies  in 
the  most  efficacions  and  pleasant  manner,  will  al¬ 
ways  hold  its  place  upon  his  shelf.  A  formulary  of 
this  kind  is  of  benefit  also  to  the  city  physician  in 
largest  practice.— Cincinnati  Clinic,  Feb.  21,  1S74. 

The  Formulary  has  already  proved  itself  accepta¬ 
ble  to  the  medical  profession,  and  we  do  not  hesitate 
to  say  that  the  third  edition  is  much  improved,  and 
of  greater  practical  value,  in  consequence  of  the  care¬ 
ful  revision  of  Prof  Maisch. — Chicago  Med.  Exam¬ 
iner,  March  1-5,  1874. 

more  complete  formulary  than  it  is  in  its  pres¬ 
ent  form  the  pharmaci-t  or  physician  could  hardly 
desire  To  the  first  some  such  work  is  indispensa¬ 
ble,  and  it  is  hardly  less  essential  to  the  practitioner 
who  comp  »auls  his  own  medicines.  .Much  of  what 
is  contained  in  the  introduction  ought  to  be  com¬ 
mitted  to  memory  by  every  student  of  melioine. 
As  a  help  to  physicians  it  will  be  found  invaluable, 
and  dogibtless  will  make  its  way  into  libraries  not 
already  supplied  with  a  standard  work  of  the  kind. 
—  The  American  Practitioner,  Louisville,  July,  ’74. 


PLLIS  {BENJAMIN),  M.D. 

THE  MEDICAL  FORMULARY:  being  a  Collection  of  Prescrijdtions 

derived  from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America 
and  Europe.  Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.  The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Observations.  Twelfth  edi¬ 
tion,  carefully  revised  and  much  improved  by  Albert  H.  Smith,  M.D.  In  one  volume  Sve. 
of  376  pages,  cloth,  $3  00. 


EREIRA  {JONATHAN),  M.D.,  F.R.S.  and  L.S. 

MATERIA  MEDICA  AXD  THERAPEUTICS;  being  an  Abridg¬ 
ment  of  the  late  Dr.  Pereira’s  Elements  of  Materia  Medica,  arranged  in  conformity  with 
the  British  Pharmacopoeia,  and  adapted  to  the  use  of  Medical  Practitioners,  Chemists  and 
Druggists,  Medical  and  Pharmaceutical  Students,  Ac.  By  F.  J.  Farre,  M.D. ,  Senior 
Physician  to  St.  Bartholomew’s  Hospital,  and  London  Editor  of  the  British  Pharmacopoeia  ; 
assisted  by  Robert  Bentley,  M.R.C.S.,  Professor  of  Materia  Medica  and  Botany  to  the 
Pharmaceutical  Society  of  Great  Britain;  and  by  Robert  Warington,  F.R.S. ,  Chemical 
Operator  to  the  Society  of  Apothecaries.  With  numerous  additions  and  references  to  the 
United  States  Pharmacopoeia,  by  Horatio  C.  Wood,  M.D.,  Professor  of  Botany  in  the 
University  of  Pennsylvania.  In  one  large  and  handsome  octavo  volume  of  1040  closely 
printed  pages,  with  236  illustrations,  cloth,  $7  00;  leather,  raised  hands,  $8  00. 


DUNGLISON’S  NEW  REMEDIES.  WITH  FORMFL.® 
FOR  THEIR  PREPARATION  AND  ADMINISTRA¬ 
TION.  Seventh  edition,  with  extensive  additions. 
One  vol.  8vo.,  pp.  770;  cloth.  $4  00. 

BOYLE’S  MATERIA  MEDICA  AND  THERAPEU¬ 
TICS.  Edited  by  Joseph  Carson,  M.  D.  With 
ninety-eight  illustrations.  1  vol.  8vo.,  pp.  700, 
cloth.  $3  00. 

CARSON’S  SYNOPSIS  OF  THE  LECTURES  ON  MA¬ 
TERIA  MEDICA  AND  PHARMACY,  delivered  in 
the  University  of  Pennsylvania,  Fourth  and  re¬ 
vised  edition.  Cloth,  $3. 


IHRISTISON’S  DISPENSATORY.  With  copious  ad 
5tud  large  wood -engravings.  Bv  R. 
Eulesfkld  Griffith,  M.D.  One  vol.  Svo.,  pp.  1000; 
cloth.  ^4  00. 

CARPENTER’S  PRIZE  ESSAY  ON  THE  USE  OF 
Alcoholic  Liqvors  in  Health  and  Disease.  New 
edition,  with  a  Preface  by  D.  F.  Condie.  M.D.,  and 
explanations  of  scientific  words.  In  one  neat  ]2mo. 
volume,  pp.  178,  cloth.  60  cents. 

De  JONGH  on  the  THREE  KINDS  OF  COD-LITER 
Oil,  with  their  Chemical  and  Therapeutic  Pro¬ 
perties.  1  vol.  12mo.,  cloth.  75  cents. 


14 


Henry  C.  Lea’s  Publications — {Pathology^  Sc.) 


PEiXWlCK  (SAMUEL),  M.D., 

■J-  Assistant  Vhysician  to  the  London  Hospital. 

THE  STUDENT’S  GUIDE  TO  MEDICAL  DIAGNOSIS.  From  the 

Third  Revised  and  Enlarged  English  Edition.  With  eighty-four  illustrations  on  wood. 
In  one  very  handsome  volume,  royal  12mo.,  cloth,  $2  25.  {Just  Issued.) 

The  very  great  success  which  this  work  has  obtained  in  England,  shows  that  it  has  supplied  an 
admitted  want  among  elementary  books  for  the  guidance  of  students  and  junior  practitioners. 
Taking  up  in  order  each  portion  of  the  body  or  class  of  disease,  the  author  has  endeavored  to 
present  in  simple  language  the  value  of  sjunptoms,  so  as  to  lead  the  student  to  a  correct  appreci¬ 
ation  of  the  pathological  changes  indicated  by  them.  The  latest  investigations  have  been  care¬ 
fully  introduced  into  the  present  edition,  so  that  it  may  fairly  be  considered  as  on  a  level  with 
the  most  advanced  condition  of  medical  science. 


Of  the  many  guide-books  on  medical  diagnosis, 
claimed  to  be  written  for  the  special  instruction  of 
students,  this  is  the  best.  The  author  is  evidently  a 
well-read  and  accomplished  phy.sician, and  he  knows 
how  to  ‘each  practical  medicine.  The  charm  of  sim¬ 
plicity  is  not  the  lea.^tint^restingfeaturein  the  man¬ 
ner  in  which  I)r.  Fenwick  conveys  instruction.  There 
are  few  books  of  this  size  on  practical  medicine  that 
contain  so  much  and  convey  it  so  well  as  the  volume 
before  us.  It  is  a  book  we  can  sincerely  recommend 
to  the  student  for  direct  instruction,  and  to  the  prac¬ 
titioner  as  a  ready  and  useful  aid  to  his  memory. — 
Am.  Journ.  of  Syphilography,  Jan.  1874. 

It  covers  the  ground  of  medical  diagnosis  in  a  con¬ 


cise,  practical  manner,  well  calculated  to  assist  the 
student  in  forming  a  correct,  thorough,  and  system¬ 
atic  method  of  examination  and  diagnosis  of  disease. 
The  illustrations  are  numerous,  and  finely  executed. 
Those  illustrative  of  the  microscopic  appearance  of 
morbid  tissue,  &c.,  are  especially  clear  and  distinct. 
— Chicago  Med.  Examiner,  Nov.  187.S. 

So  far  superior  to  any  ofifered  to  students  that  the 
colleges  of  this  country  should  recommend  it  to  their 
respective  classes. — N.  0.  Med.  and  Surg.  Journ., 
March,  1874. 

This  little  book  ought  to  be  in  the  possession  of 
every  n  edical  student. — Boston  Medical  and  Surg. 
Journ.,  Jan.  15,  1874. 


flREEN  (T.  HENRY),  M.D., 

Lecturer  on  Pathology  and  Morbid,  Anatomy  at  Oharing-Cross  Hospital  Medical  School. 

PATHOLOGY  AND  MORBID  ANATOMY.  With  numerous  Illus¬ 
trations  on  Wood.  In  one  very  handsome  octavo  volume  of  over  250  pages,  cloth,  $2  50. 
{Lately  Published.) 

We  have  been  very  much  pleased  by  our  perusal  of  i  thology  and  morbid  anatomy.  The  author  shows  that 
this  little  volume.  It  is  the  only  one  of  the  kind  with  he  has  been  not  only  a  student  of  the  teachings  of  his 
which  we  are  acquainted,  and  practitioners  as  well  ;  confreres  in  this  branch  of  science,  but  a  practical 
as  students  will  find  it  a  very  useful  guide;  for  the  !  and  conscientious  laborer  in  the  post-mortem  cham- 
information  is  up  to  the  day,  well  and  compactly  ar-  j  ber.  The  work  will  provea  useful  one  to  the  great 
ranged,  without  being  at  all  scanty. — London  Lan  mass  of  students  and  practitioners  whose  time  for  de- 
cet,  Oct.  7,  1871.  j  votioa  to  this  class  of  studies  is  limited.— Am.  Journ. 

It  embodies  in  a  comparatively  small  space  a  clear  I  of  Bibliography,  April,  1872. 
statement  of  the  present  state  of  our  knowledge  of  pa-  I 


GLUGE’S  ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 
Translated,  with  Notes  and  Additions,  by  Jo.seph 
Leidy,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  320  copper-plate  figures,  plain  and 
colored,  cloth.  $4  00. 

JONES  AND  SIEYEKING’S  PATHOLOGICAL  ANA¬ 
TOMY.  With  397  wood-cuts.  1  vol.  8vo.,  of  nearly 
750  pages,  cloth.  $3  50. 

HOLLAND’S  MEDICAL  NOTES  AND  REFLEC¬ 
TIONS.  1  vol.  8vo.,  pp.  -500,  cloth.  $3  50 

WHAT  TO  OBSERVE  AT  THE  BEDSIDE  AND  AFTEI. 
Death  in  Medical  Cases.  Published  under  thi 
authority  of  the  London  Society  for  Medical  Obser¬ 
vation.  From  the  second  London  edition.  1  vol. 
royal  12mo.,  cloth.  $1  00. 


liA  ROCHE  ON  YELLOW  FEVER,  considered  in  its 
Historical,  Pathological,  Etiological,  and  Therapeu¬ 
tical  Relations.  In  two  large  and  handsome  octavo 
volumes  of  nearly  1.500  pages,  cloth.  $7  00. 

LAYCOCK’S  LECTURES  ON  THE  PRINCIPLES 
AND  Methods  op  Medical  Observation  and  Re¬ 
search.  For  the  use  of  advanced  students  and 
junior  practitioners.  In  one  very  neat  royal  12mo. 
volume,  cloth.  $1  00. 

BARLOW’S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  Condie, 
M  D.  1  vol.  8vo.,  pp,  600.  cloth.  50. 

TODD’S  CLINICAL  LECTURES  ON  CERTAIN  ACUTE 
Diseases.  In  one  neat  octavo  volume,  of  320  pages, 
cloth.  i|2  60. 


OTURGES  (OCTAVIUS),  M.D.  Contah., 

LA  Fellow  of  the  Royal  College  of  Physicians,  &c.  &c. 

AN  INTRODUCTION  TO  THE  STUDY  OF  CLINICAL  MED¬ 
ICINE.  Being  a  Guide  to  the  Investigation  of  Disease,  for  the  Use  of  Students.  In  one 
handsome  12mo.  volume,  cloth,  $1  25.  {Just  Issued.) 


T)  A  VIS  (NA  THAN  S.), 

Prof,  of  Principles  and  Practice  of  Medicine,  etc.,  in  Chicago  Med.  College. 

CLINICAL  LECTURES  ON  VARIOUS  IMPORTANT  DISEASES; 

being  a  collection  of  the  Clinical  Lectures  delivered  in  the  Medical  Wards  of  Mercy  Hos¬ 
pital,  Chicago.  Edited  by  Frank  II.  Davis,  M.D.  Second  edition,  enlarged.  In  one 
handsome  royal  12mo.  volume.  Cloth,  $1  75.  {Now  Ready.) 


^TOKES  {^YILLIAM),  M.D.,  D.C.L.,  F.R.S., 

RJ  Regius  Professor  of  Phy.sic  in  the  Univ.  of  Driblin,  &c. 

LECTURES  ON  FEVER,  delivered  in  the  Theatre  of  the  Meath  Hos¬ 
pital  and  County  of  Dublin  Infirmary.  Edited  by  John  William  Moore,  M.D  ,  Assistant 
Physician  to  the  Cork  Street  Fever  Hospital.  In  one  neat  octavo  volume.  {Preparing.) 
To  appear  in  the  “Medical  News  and  Library”  for  1875. 


Henry  C.  Lea’s  Publications— (Practice  of  Medicine) 


15 


fi^LINT  {AUSTIN),  M.D., 

A.  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Med.  College,  N.  7. 


A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE  OF 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fourth 
edition,  revised  and  enlarged.  In  one  large  and  closely  printed  octavo  volume  of  about  1100 
pages ;  cloth,  $6  00  ;  or  strongly  hound  in  leather,  with  raised  bands,  $7  00.  iJust  Issued.) 

By  common  consent  of  the  English  and  American  medical  press,  this  work  has  been  assigned 
to  the  highest  position  as  a  complete  and  compendious  text-book  on  the  most  advanced  condition 
of  medical  science.  At  the  very  moderate  price  at  which  it  is  offered  it  will  be  found  one  of  the 
cheapest  volumes  now  before  the  profession.  A 


Admirable  and  unequalled.  —  Western  Journal  of 
Medicine,  Nov.  1869. 

Dr.  Flint’s  work,  though  claiming  no  higher  title 
than  that  of  a  text-book,  is  really  more.  He  is  a  man 
of  large  clinical  experience,  and  his  book  is  full  of 
such  masterly  descriptions  of  disease  as  can  only  be 
drawn  by  a  man  intimately  acquainted  with  their 
various  forms.  It  is  not  so  long  since  we  had  the 
pleasure  of  reviewing  his  first  edition,  and  we  recog¬ 
nize  a  great  improvement,  especially  in  the  general 
part  of  the  work.  It  is  a  work  which  we  can  cordially 
recommend  to  our  readers  as  fully  abreast  of  the  sci¬ 
ence  of  the  day. — Edinburgh  Med.  Journal,  Oct.  ’69. 

One  of  the  best  works  of  the  kind  for  the  practi¬ 
tioner,  and  the  most  convenient  of  all  for  the  student. 
— Am.  Journ.  Med.  Sciences,  Jan.  1869. 

This  work,  which  stands  pre-eminently  as  the  ad¬ 
vance  standard  of  medical  science  up  to  the  present 
time  in  the  practice  of  medicine,  has  for  its  author 
one  who  is  well  and  widely  known  as  one  of  the 
leading  practitioners  of  this  continent.  In  fact,  it  is 
seldom  that  any  work  is  ever  issued  from  the  press 
more  deserving  of  universal  I’ecommendation. — Do¬ 
minion  Med  Journal,  May,  1869. 

The  third  edition  of  this  most  excellent  book  scarce¬ 
ly  needs  any  commendation  from  us.  The  volume, 
as  it  stands  now,  is  really  a  marvel :  first  of  all,  it  is 


few  notices  of  previous  editions  are  subjoined, 
jxcellently  printed  and  bound — and  we  encounter 
that  luxury  of  America,  the  ready-cut  pages,  which 
the  Yankees  are  ’cute  enough  to  insist  upon — nor  are 
these  by  any  means  trifles  ;  but  the  contents  of  the 
book  are  astonishing.  Not  only  is  it  wonderful  that 
my  one  man  can  have  gra.sped  in  his  mind  the  whole 
mope  of  medicine  with  that  vigor  which  Dr.  Flint 
shows,  but  the  condensed  yet  clear  way  in  which 
".his  is  done  is  a  perfect  literary  triumph.  Dr.  Flint 
!S  pre-eminently  one  of  the  strong  men,  whose  right 
’o  do  this  kind  of  thing  is  well  admitted  ;  and  we  say 
10  more  than  the  truth  when  we  affirm  that  he  is 
very  nearly  the  only  living  man  that  could  do  it  with 
such  results  as  the  volume  before  us. — The  London 
Practitioner,  March,  1869. 

This  is  in  some  respects  the  best  text-book  of  medi¬ 
cine  in  our  language,  and  it  is  highly  appreciated  on 
the  other  side  of  the  Atlantic,  inasmuch  as  the  first 
edition  was  exhausted  in  a  few  months.  The  second 
edition  was  little  more  than  a  reprint,  but  the  present 
las,  as  the  author  says,  been  thoroughly  revised. 
Much  valuable  matter  has  been  added,  and  by  mak¬ 
ing  the  type  smaller,  the  bulk  of  the  volume  is  not 
much  increased.  The  weak  point  in  many  American 
works  is  pathology,  but  Dr.  Flint  has  taken  peculiar 
pains  on  this  point,  greatly  to  the  value  of  the  book, 
— London  3Ied.  Times  and  Gazette,  Feb.  6,  1869. 


TDF  THE  SAME  AUTHOR. 

ESSAYS  ON  CONSERVATIVE  MEDICINE  AND  KINDRED 

TOPICS.  In  one  very  handsome  royal  12mo.  volume.  Cloth,  $1  38.  {Jtest  Issued.) 

CONTENTS, 

I.  Conservative  Medicine.  II.  Conservative  Medicine  as  applied  to  Therapeutics.  III.  Con¬ 
servative  Medicine  as  applied  to  Hygiene,  IV.  Medicine  in  the  Past,  the  Present,  and  the  Fu¬ 
ture.  V.  Alimentation  in  D  sease.  VI.  Tolerance  of  Disea.se.  VII.  On  the  Age  cy  of  the 
Mind  in  Eiiology,  Prophylaxis,  and  Therapeutics.  VIII.  Divine  design  as  exemplified  in  the 
Natural  History  of  Disease. 


WA  TSON  [THOMAS],  M.  D.,  ^c. 

LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE  OF 

PHYSIC.  Delivered  at  King’s  College,  London.  A  new  American,  from  the  Fifth  re¬ 
vised  and  enlarged  English  edition.  Edited,  with  additions,  and  several  hundred  illustra- 
ations,  by  Henry  Hartshorne,  M.D.,  Professor  of  Hygiene  in  the  University  of  Pennsylv. 


nia.  In  two  large  and  handsome  8vo.  vols. 

It  is  a  subject  for  congratulation  and  for  thankful¬ 
ness  that  Sir  Thomas  Watson,  during  a  period  of  com¬ 
parative  leisure,  after  a  long,  laborious,  and  most 
honorable  professional  career,  while  retaining  full 
possession.of  his  high  mental  faculties,  should  have 
employed  the  opportunity  to  submit  his  Lectures  to 
a  more  thorough  revision  than  was  possible  during 
the  earlier  and  busier  period  of  his  life.  Carefully 
passing  in  review  some  of  the  most  intricate  and  im¬ 
portant  pathological  and  pi’actical  questions,  the  re¬ 
sults  of  his  clear  insight  and  his  calm  judgment  are 
now  recorded  for  the  benefit  of  mankind,  in  language 
which,  for  precision,  vigor,  and  classical  elegance,  has 
rarely  been  equalled,  and  never  surpassed  The  re¬ 
vision  has  evidently  been  most  carefully  done,  and 
the  results  appear  in  almost  every  page. — Brit.  Med. 
Journ.,  Oct.  14,  1871. 

The  lectures  are  so  well  known  and  so  justly 
appreciated,  that  it  is  scarcely  necessary  to  do 
more  than  call  attention  to  the  special  advantages 
of  the  last  over  previous  editions.  The  author's 


]!loth,  $9  00  ;  leather,  $11  00,  {Lately  Published.) 

rare  combination  of  great  scientific  attainments  com¬ 
bined  with  wonderful  forensic  eloquence  has  exerted 
extraordinary  influence  over  the  last  two  generations 
of  phy.sicians.  His  clinical  descriptions  of  most  di.s- 
eases  have  never  been  equalled;  and  on  this  score 
at  least  his  work  will  live  long  in  the  future.  The 
work  will  be  sought  by  all  who  appreciate  a  great 
book. — Amer.  Journ.  of  Syphilography,  July,  1872. 

We  are  exceedingly  gratified  at  the  reception  of 
this  new  edition  of  Watson,  pre-eminently  the  prince 
of  English  authors,  on  “Practice.”  We,  who  read 
the  first  edition  shall  never  forget  the  great  pleasure 
and  profit  we  derived  from  its  graphic  delineations 
of  disease,  its  vigorous  style  and  splendid  English. 
Maturity  of  years,  extensive  observation,  profound 
re.search,  and  yet  continuous  enthu.siasm,  have  com¬ 
bined  to  give  us  in  this  latest  edition  a  model  of  pro¬ 
fessional  excellence  in  teaching  with  rare  beauty  in 
the  mode  of  communication.  But  this  classic  needs 
no  eulogium  of  ours, — Chicago  Med.  Journ.,  July, 
1872 


fiUNGLISON,  FORBES,  TWEEDIE,  AND  CONOLLY. 

•^THE  CYCLOPJEDIA  OF  PRACTICAL  MEDICINE:  comprising 

Treatises  on  the  Nature  and  Treatment  of  Diseases,  Materia  Medica  and  Therapeutics, 
Diseases  of  Women  and  Children,  Medical  Jurisprudence,  <fec.  &c.  In  four  large  super-royal 
octavo  volumes,  of  3254  double-columned  pages,  strongly  and  handsomely  bound  in  leather, 
$15;  cloth,  $11. 


16 


Henry  C.  Lea’s  Publications — {Practice  of  Medicine), 


TTARTSHORNE  [HENRY),  M.D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDl- 

CINE.  A  handy-book  for  Students  and  Practitioners.  Fourth  edition,  revised  and  im¬ 
proved.  With  about  one  hundred  illustrations.  In  one  handsome  royal  ]2mo.  volume, 
of  about  550  pages,  cloth,  $2  63;  half  bound,  $2  88.  {Just  Ready.) 

The  thorough  manner  in  which  the  author  has  labored  to  fully  represent  in  this  favorite  hand¬ 
book  the  most  advanced  condition  of  practical  medicine  is  shown  by  the  fact  that  the  present 
edition  contains  more  than  250  additions,  representing  the  investigations  of  172  authors  not  re¬ 
ferred  to  in  previous  editions.  Notwithstanding  an  enlargement  of  the  page,  the  size  has  been 
increased  by  sixty  pages.  A  number  of  illustrations  have  been  introduced  which  it  is  hoped 
will  facilitate  the  comprehension  of  details  by  the  reader,  and  no  effort  has  been  spared  to  make 
the  volume  worthy  a  continuance  of  the  very  great  favor  with  which  it  has  hitherto  been  received. 


The  work  is  brought  fully  up  with  all  the  recent 
advances  in  medicine,  is  admirably  condensed,  and 
yet  sufficiently  explicit  for  all  the  purposesintended, 
thus  making  it  by  far  the  best  work  of  its  character 
ever  published. — Cincinnati  Clinic,  Oct.  24,  1874. 

We  have  already  had  occasion  to  notice  the  previ¬ 
ous  editions  of  this  work.  It  is  excellent  of  its  kind. 
The  author  has  given  a  very  careful  revision,  in  view 
of  the  rapid  progress  of  medical  science. — N.  Y.  Med. 
Journ.,  Nov.  1874. 


Without  doubt  tbe  best  book  of  the  kind  published 
in  the  English  language. — St.  Louis  Med.  andSurg. 
Journ.,  Nov.  1874. 

Asa  handbook,  which  clearly  sets  forth  the  essen¬ 
tials  of  the  PRINCIPLES  AND  PRACTICE  OF  MEDICINE,  We 
do  not  know  of  its  equal. —  Va.  Med.  Monthly. 

As  a  brief,  condensed,  but  comprehensive  hand¬ 
book,  it  cannot  be  improved  upon. — Chicago  Med. 
Examiner,  Nov.  15,  1874. 


PAVY[F.  W.),M.D.,F.R.S., 

Senior  Asst.  Physician  to  and  Lecturer  on  Physiology,  at  Guy's  Hospital,  &c. 

A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION;  its  Disor- 

ders  and  their  Treatment.  From  the  second  London  edition.  In  one  handsome  volume, 
small  octavo,  cloth,  $2  00. 

JDT  THE  SAME  AUTHOR.  {Just  Ready. 

A  TREATISE  ON  FOOD  AND  DIETETICS,  PHYSIOLOGI¬ 
CALLY  AND  THERAPEUTICALLY  CONSIDERED.  In  one  handsome  octavo  volume 
of  nearly  600  pages,  cloth,  $4  75. 

SUMMARY  OF  CONTENTS. 

Introductory  Remarks  on  the  Dynamic  Relations  of  Food — On  the  Origination  of  Food — The 
Constituent  Relations  of  Food — Alimentary  Principles,  their  Classification,  Chemical  Relations, 
Digestion,  Assimilation,  and  Physiological  Uses — Nitrogenous  Alimentary  Principles — Non-Ni- 
trogenous  Alimentary  Principles — The  Carbo-Hydrates — The  Inorganic  Alimentary  Principles — 
Alimentary  Substances — Animal  Alimentary  Substances — Vegetable  Alimentary  Substances — 
Beverages — Condiments — The  Preservation  of  Food — Principles  of  Dietetics — Practical  Dietetics 
— Diet  of  Infants — Diet  for  Training — Therapeutic  Dietetics — Dietetic  Preparations  for  the  Inva¬ 
lid — Hospital  Dietaries. 


flHAMBERS  [T.  K.),  M.D.  [Now  Ready.) 

Consulting  Physician  to  St.  Mary's  Hospiial,  London,  &e. 

A  MANUAL  OF  DIET  AND  REGIMEN  IN  HEALTH  AND  SICK- 


NESS.  In  one  handsome  octavo  volume.  Cloth,  $2  75. 

The  aims  of  this  handbook  are  purely  practical,  and  therefore  it  has  not  been  thought  right 
to  increase  its  size  by  the  addition  of  the  chemical,  botanical,  and  industrial  learning  which 
rapidly  collects  round  the  nucleus  of  every  article  interesting  as  an  eatable.  Space  has  been 
thus  gained  for  a  full  discussion  of  many  matters  connecting  food  and  drink  with  the  daily  cur¬ 
rent  of  social  life,  which  the  position  of  the  author  as  a  practising  physician  has  led  him  to 
believe  highly  important  to  the  present  and  future  of  our  race. — Preface. 

SUMMARY  OF  CONTENTS. 

Part  I.  General  Dietetics.  Chap.  I.  Theories  of  Dietetics.  II.  On  the  Choice  of  Food.  III. 
On  the  Preparation  of  Food.  IV.  On  Digestion  and  Nutrition. 

Part  II.  Special  Dietetics  of  Health.  Chap.  I.  Begimen  of  Infancy  and  Motherhood.  II. 
Regimen  of  Childhood  and  Youth.  III.  Commercial  Life.  IV.  Literary  and  Professional  Life. 
V.  Noxious  Trades.  VI.  Athletic  Training.  VII.  Hints  for  Healthy  Travellers.  VIII.  Effects 
of  Climate.  IX.  Starvation,  Poverty,  and  Fasting.  X.  The  Decline  of  Life.  XI.  Alcohol. 

Part  III.  Dietetics  in  Sickness.  Chap.  I.  Dietetics  and  Regimen  in  Acute  Fevers.  II.  The 
Diet  and  Regimen  of  certain  other  Inflammatory  States.  III.  The  Diet  and  Regimen  of  Weak 
Digestion.  IV.  Gout  and  Rheumatism.  V.  Gravel,  Stone,  Albuminuria,  and  Diabetes.  VI. 
Deficient  Evacuation.  VII.  Nerve  Disorders.  VIII.  Scrofula,  Rickets,  and  Consumption.  IX. 
Diseases  of  Heart  and  Arteries. 


J^Y  THE  SAME  AUTHOR.  {Lately  Published.) 

RESTORATIVE  MEDICINE.  An  Harveian  Annual  Oration.  With 

Two  Sequels.  In  one  very  handsome  volume,  small  12mo.,  cloth,  $1  00. 

pRINTON  [WILLIAM),  M.D.,  F.R.S. 

■^LECTURES  ON  THE  DISEASES  OF  THE  STOMACH;  with  an 

Introduction  on  its  Anatomy  and  Physiology.  From  the  second  and  enlarged  London  edi¬ 
tion.  With  illustrations  on  wood  In  one  handsome  octavo  volume  of  about  300  pages 
cloth,  $3  25. 


Henry  C.  Lea’s  Publications 


n 


l^LINT  {AUSTIN),  M.D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med.  College,  N.  Y. 

A  PRACTICAL  TREATISE  OX  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.  Second  revised  and  enlarged 
edition.  In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  $4. 


Dr.  Flint  chose  a  difficult  subject  for  his  researches, 
and  has  shown  remarkable  powers  of  observation 
and  reflection,  as  well  as  great  industry,  in  his  treat¬ 
ment  of  it.  His  book  must  be  considered  the  fullest 
and  clearest  practical  treatise  on  those  subjects,  and 
should  be  in  the  hands  of  all  practitioners  and  stu¬ 
dents.  It  is  a  credit  to  American  medical  literature. 
— Amer.  Journ.  of  the  Med.  Sciences,  July,  1860. 

We  question  the  fact  of  any  recent  American  author 
In  our  profession  being  more  extensively  known,  or 
more  deservedly  esteemed  in  this  country  than  Dr. 
Flint.  We  willingly  acknowledge  his  success,  more 
particularly  in  the  volume  on  diseases  of  the  heart, 
jn  making  an  extended  personal  clinical  study  avail¬ 


able  for  purposes  of  illustration,  in  connection  with 
cases  which  have  been  reported  by  other  trustworth  y 
observers. — Brit,  and  For.  Med.-Chirurg.  Review. 

I  In  regard  to  the  merits  of  the  work,  we  have  no 
,  hesitation  in  pronouncing  it  full,  accurate,  and  judi¬ 
cious.  Considering  the  present  state  of  science,  such 
a  work  was  much  needed.  It  should  be  in  the  hands 
of  every  practitioner. — Chicago  Med.  Journ. 

With  more  than  pleasure  do  we  hail  the  advent  of 
this  work,  for  it  fills  a  wide  gap  -on  the  list  of  text¬ 
books  for  our  schools,  and  is,  for  the  practitioner,  the 
most  valuable  practical  work  of  its  kind. — H.  0.  Med. 
News. 


THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA¬ 
TION  OF  THE  CHEST  AND  THE  DIAOSOSIS  OF  DISEASES  AFFECTINO  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 


of  595  pages,  cloth,  $4  50. 

Dr.  Flint’s  treatise  is  one  of  the  most  trustworthy 
guides  which  we  can  consult.  The  style  is  clear  and 
distinct,  and  is  also  concise,  being  free  from  that  tend¬ 
ency  to  over-refinement  and  unnecessary  minuteness 
which  characterizes  many  works  on  the  same  sub¬ 
ject. — Dublin  Medical  Press,  Feb.  6,  1867. 

The  chapter  on  Phthisis  is  replete  with  interest ; 
and  his  remarks  on  the  diagnosis,  especially  in  the 
early  stages,  are  remarkable  for  their  acumen  and 
great  practical  value.  Dr.  Flint’s  style  is  ciear  and 
elegant,  and  the  tone  of  freshness  and  originality 


which  pervades  his  whole  work  lend  an  additional 
force  to  its  thoroughly  practical  character,  which 
cannot  fail  to  obtain  for  it  a  place  as  a  standard  work 
on  diseases  of  the  respiratory  system. — London 
Lancet,  Jan.  IP,  1867. 

This  is  an  admirable  book.  Excellent  in  detail  and 
execution,  nothing  better  could  be  desired  by  the 
practitioner.  Dr.  Flint  enriches  his  subject  with 
much  solid  and  not  a  little  original  observation.— 
Ranking's  Abstract,  Jan.  1867. 


B  Y  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  OX  PHTHISIS— DIAGNOSIS,  PROG¬ 
NOSIS,  AND  TREATMENT.  IN  A  SERIES  OF  CLINICAL  STUDIES.  A  new  work, 
in  preparation  for  early  publication.  In  one  handsome  octavo  volume. 

A  brief  table  of  contents  is  subjoined: — 

Chap.  I.  Morbid  Anatomy.  II.  Etiology.  III.  Symptomatic  Events  and  Complications. 
IV.  Fatality  and  Prognosis.  V.  Treatment.  VI.  Physical  Signs  and  Diagnosis. 

T^ULLER  [HENRY  WILLIAM),  M.  D., 

Physician  to  St.  George's  Hospital,  London. 

ON  DISEASES  OF  THE  LUNGS  AND  AIR-PASSAGES.  Their 

Pathology,  Physical  Diagnosis,  Symptoms,  and  Treatment.  From  the  second  and  revised 
English  edition.  In  one  handsome  octavo  volume  of  about  500  pages,  cloth,  $3  50. 


^ILLIAMS  [C.  J.  B.),  M.D., 

Senior  Consulting  Physician  to  the  Hospital  for  Consumption,  Brompton,  and 

ypLLIAMS  [CHARLES  T.),  M.D., 

Physician  to  the  Hospital  for  Consumption. 

PULMONARY  CONSUMPTION;  Its  Nature,  Yarieties,  and  Treat- 

ment.  With  an  Analysis  of  One  Thousand  Cases  to  exemplify  its  duration.  In  one  neat 
octavo  volume  of  about  350  pages,  cloth,  $2  50.  {Lately  Published.) 


He  can  still  speak  from  a  more  enormous  experi¬ 
ence,  and  a  closer  study  of  the  morbid  processes  in¬ 
volved  in  tuberculosis,  than  most  living  men.  He 
owed  it  to  himself,  and  to  the  importance  of  the  sub¬ 
ject,  to  embody  his  views  in  a  separate  work,  and 
we  are  glad  that  he  has  accomplished  this  duty. 


After  all,  the  grand  teaching  which  Dr  Williams  has 
for  the  profession  is  to  be  found  in  his  therapeutical 
chapters,  and  in  the  history  of  individual  cases  ex¬ 
tended,  by  dint  of  care,  over  ten,  twenty,  thirty,  and 
aven  forty  years. — London  Lancet,  Oct.  21,  1871. 


LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.,  cloth.  WALSHE  ON  THE  DISEASES  OF  THE  HEART  AND 
of  500  pages.  Price  $3  00.  GREAT  VESSELS.  Third  American  edition.  In 

SMITH  ON  CONSUJIPTION  ;  ITS  EARLY  AND  RE-  1  420  pp.,  cloth.  $3  00. 

MEDIABLE  STAGES.  1  vol.  8vo.,  pp.  254.  $2  25.  | 

J^OX  ( TTYL5'6)A0,  M.D., 

Holme  Prof,  of  Clinical  Med.,  University  Coll.,  London. 

THE  DISEASES  OF  THE  STOMACH:  Being  the  Third  Edition  of 

the  “Diagnosis  and  Treatment  of  the  Varieties  of  Dyspepsia.”  Revised  and  Enlarged. 
With  illustrations.  In  one  handsome  octavo  volume,  cloth,  $2  00.  {Now  Ready.) 

Dr.  Fox  has  put  forth  a  volume  of  uncommon  ex-  rank  among  works  that  treat  of  the  stomach.— Am* 
cellence,  which  we  feel  very  sure  will  take  a  high  Practitioner,  March,  1873. 


18 


Henry  C.  Lea’s  Publications — {Practice  of  Medicine) 


jOOBERTS  (  WILLIAM),  M.  D.. 

^  Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  &c. 

A  PRACTICAL  TREATISE  ON  URINARY  AND  RENAL  DIS- 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engravings.  Sec¬ 
ond  American,  from  the  Second  Revised  and  Enlarged  London  Edition.  In  one  large 
and  handsome  octavo  volume  of  616  pages,  with  a  colored  plate  ;  cloth,  $4  50.  (Lately 
Published.) 

The  author  has  subjected  this  work  to  a  very  thorough  revision,  and  has  sought  to  embody  in 
it  the  results  of  the  latest  experience  and  investigations.  Although  every  effort  has  been  made 
to  keep  it  within  the  limits  of  its  former  size,  it  has  been  enlarged  by  a  hundred  pages,  many 
new  wood-cuts  have  been  introduced,  and  also  a  colored  plate  representing  the  appearance  of  the 
different  varieties  of  urine,  while  the  price  has  been  retained  at  the  former  very  moderate  rate. 

The  plan,  it  will  thus  be  seen,  is  very  complete,  diseases  we  have  examined.  It  is  peculiarly  adapted 
and  the  manner  in  which  it  has  been  carried  out  is  to  the  wants  of  the  majority  of  American  practltion- 
in  the  highest  degree  satisfactory.  The  characters  ers  from  its  clearness  and  simple  announcement  of  the 
of  the  different  deposits  are  very  well  described,  and  facts  in  relation  to  diagnosis  and  treatment  of  urinary 
the  microscopic  appearances  they  present  are  illus- ,  disorder.s,  and  contains  in  condensed  form  the  investi- 
trated  by  numerous  well  executed  engravings.  It  gations  of  Bence  Jones,  Bird,  Beale,  Hassall,  Prout, 
only  remains  to  ns  to  strongly  recommend  to  our  and  a  host  of  other  well-known  writers  upon  this  sub¬ 
readers  Dr.  Roberts’s  work,  as  containing  an  admira-  |  ject.  The  characters  of  urine,  physiological  and  pa- 
ble  resume  of  the  present  state  of  knowledge  of  uri-  thological,  as  indicated  to  the  naked  eye  as  well  as  by 
nary  diseases,  and  as  a  safe  and  reliable  guide  to  the  microscopical  and  chemical  investigations,  are  con- 
clinical  observer. — Edin.  Med.  Jour.  \  cisely  represented  both  by  description  and  by  well 

The  most  completeand  practical  treatise  upon  renal  executed  engravings.  Cincinnati  Journ.  of  Med. 


J)  ASH  AM  {W.R.),  M.D., 

Senior  Physician  to  the  Westminster  Hospital,  &c. 


RENAL  DISEASES:  a  Clinical  Guide  to  their  Diagnosis  and  Treatment* 

With  illustrations.  In  one  neat  royal  12mo.  volume  of  304  pages,  cloth,  $2  00. 


The  chapters  on  diagnosis  and  treatment  are  very 
good,  and  the  student  and  young  practitioner  will 
find  them  full  of  valuable  practical  hints.  The  third 
part,  on  the  urine,  is  excellent,  and  we  cordially 
recommend  its  perusal.  The  author  has  arranged 
his  matter  in  a  somewhat  novel,  and,  we  think,  use¬ 
ful  form.  Here  everything  can  be  easily  found,  and, 
what  is  more  important,  easily  read,  for  all  the  dry 


details  of  larger  books  here  acquire  a  new  interest 
from  the  author’s  arrangement.  This  part  of  the 
book  is  full  of  good  work. — Brit,  and  For.  Medico- 
Ihirurgical  Review,  July,  1870. 

The  easy  descriptions  and  compact  modes  of  state¬ 
ment  render  the  book  pleasing  and  convenient. — Am. 
Journ.  Med.  Sciences,  July,  1870. 


T  INCOLN  [D.  F.).  31. D., 

Physician  to  the  Department  of  Nervous  Diseases,  Bo.ston  Di.spensary. 

ELECTRO  THERAPEUTICS;  A  Concise  Manual  of  Medical  Electri- 

city.  In  one  very  neat  royal  12mo.  volume,  cloth,  with  illustrations,  50.  (Just  Ready.) 


The  work  is  convenient  in  size,  its  descriptions  of 
methods  and  appliances  are  sufficiently  complete  for 
the  general  practitioner,  and  the  chapters  on  Electro¬ 
physiology  and  diagnosis  are  well  written  and  read¬ 
able.  For  those  who  wish  a  handy-book  of  directions 
for  the  employment  of  galvanism  in  medicine,  this 
will  serve  as  a  very  good  and  reliable  guide. — New 
Remedies,  Oct.  1874. 

It  is  a  well  written  work,  and  calculated  to  meet 
the  demands  of  the  busy  practitioner.  It  contains 
the  latest  researches  in  this  important  branch  of  med¬ 
icine. — Peninsxdar  Journ.  of  Med.,  Oct.  1874. 

Eminently  practical  in  character.  It  will  amply 
repay  any  one  for  a  careful  perusal. — Leavenworth 
Med.  Herald,  Oct.  1874. 


This  little  book  is,  considering  its  size,  one  of  the 
very  best  of  the  Engli.sh  treatises  on  its  subject  that 
has  come  to  our  notice,  possessing,  among  others,  the 
rare  merit  of  dealing  avowedly  and  actually  with 
principles,  mainly,  rather  than  with  practical  detail.s, 
thereby  supplying  a  real  want,  instead  of  helping 
merely  to  flood  the  literary  market  Dr.  Lincoln  s 
style  is  usually  remarkably  clear,  and  the  whole 
book  is  readable  and  interesting. — Boston  Med.  and 
Surg.  Journ.,  July  23,  1S74. 

We  have  here  in  a  small  compass  a  great  deal  of 
valuable  information  upon  the  subject  of  Medical 
Electricity. — Canada  Med.  and  Surg.  Journ..  Nov. 
1874. 


J^EE  [HENRY], 

Prof,  of  So.rgery  at  the  Royal  College  of  Surgeons  of  England,  etc. 

LECTURES  ON  SYRHILtS  .A.ND  ON  SOME  FORMS  OF  LOC.AL 

DISEASE  AFFECTING  PRINCIPALLY  THE  ORGANS  OF  GENERATION.  In  one 
handsome  octavo  volume. 

CJOKTTElSrTS. 


Lectures  I.,  II.,  III.  General.  —  IV.  Treatment  of  Syphilis — V.  Treatment  of  Particular 
and  Modified  Syphilitic  Affections — VI.  Second  S  age  of  Lues  Venerea;  Treatment — VII.  Lo¬ 
cal  Suppurating  Venereal  Sore;  Syphilization  ;  Lymphatic  Absorption  ;  Physiological  Absorp¬ 
tion  ;  Twofold  Inoculation — VIII.  Urethral  Discharges  :  different  kinds;  Treatment;  Conclu¬ 
sions  of  Hunter  and  Ricord — IX.  Prostatic  Discharges — X.  Lymphatic  Absorption  continued  ; 
Local  Affections  ;  Warts  and  Excrescences. 


DIPHTHERIA  ;  its  Nature  and  Treat  -uent,  with  an 
account  of  the  History  of  its  Prevalence  in  vari¬ 
ous  Countries.  By  D.  D.  Slade,  M.  D.  Second  and 
revised  edition.  In  one  neat  royal  12mo.  volume, 
cloth,  $l  25. 

LECTURES  ON  THE  STUDY  OF  FEVER.  By  A. 
Hudson,  M.D.,  M.R.I.A.,  Physician  to  the  Meath 
Hospital.  In  one  vol.  8vo.,  cloth,  $2  50. 


A  TREATISE  ON  FEVER.  By  Robert  D.  Lyons, 
K  C  C.  In  one  octavo  volume  of  362  pages,  cloth, 
$2  2.5. 

CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
I  NERVOUS  DISORDERS  Bv  C.  Handfield  Jone.s, 
M.D.,  Physician  to  St.  Mary’s  Hospital,  &c.  Sec- 
I  ond  American  Edition.  In  one  handsome  octavo 
I  volume  of  348  pages,  cloth,  $3  25.  * 


Henry  C.  Lea’s  Publications — (  Venereal  Diseases^  etc.) 


19 


T>UMSTEAD  [FREEMAN  J.),  M.D., 

A-f  Professor  of  Venereal  Diseases  at  the  Ool.  of  Phys.  and  Surg.,  New  York,  Ac. 

THE  PATHOLOGY  AND  TREATMENT  OF  VENEREAL  DIS¬ 
EASES.  Including  the  results  of  recent  investigations  upon  the  subject.  Third  edition, 
revised  and  enlarged,  with  illustrations.  In  one  large  and  handsome  octavo  volume  of 
over  700  pages,  cloth,  $5  00  ;  leather,  $6  00. 

In  preparing  this  standard  work  again  for  the  press,  the  author  has  subjected  it  to  a  very 
thorough  revision.  Many  portions  have  been  rewritten,  and  much  new  matter  added,  in  order  to 
bring  it  completely  on  a  level  with  the  most  advanced  condition  of  syphilograpby,  but  by  careful 
compression  of  the  text  of  previous  editions,  the  work  has  been  increased  by  only  sixty-four  pages. 
The  labor  thus  bestowed  upon  it,  it  is  hoped,  will  insure  for  it  a  continuance  of  its  position  as  a 
complete  and  trustworthy  guide  for  the  practitioner. 


It  is  tbe  most  complete  book  with  which  we  are  ac-  ' 
quainted  in  the  language.  The  latest  views  of  the  j 
best  authorities  are  put  forward,  and  the  information  ! 
Is  well  arranged — a  great  point  for  the  student,  and 
still  more  for  the  practitioner.  The  subjects  of  vis¬ 
ceral  syphilis,  syphilitic  affections  of  the  eyes,  and 
the  treatment  of  syphilis  by  repeated  inoculations,  are 
very  fully  discussed. — London  Lancet,  Jan.  7,  1871. 

Dr.  Bumstead’s  work  is  already  so  universally 
known  as  the  best  treatise  in  the  English  language  on 
venereal  diseases,  that  it  may  seem  almost  superflu¬ 
ous  to  say  more  of  it  than  that  a  new,edition  has  been 
Issued.  But  the  author’s  industry  has  rendered  this 
new  edition  virtually  a  new  work,  and  so  merits  as  ^ 


much  special  commendation  as  if  its  predecessors  had 
not  been  published.  As  a  thoroughly  practical  book 
on  a  class  of  diseases  which  form  a  large  share  of 
nearly  every  physician’s  practice,  the  volume  before 
us  is  by  far  the  best  of  which  we  have  knowledge. — 
N.  Y.  Medical  Gazette,  Jan.  28,  1871. 

It  is  rai'e  in  the  history  of  medicine  to  find  any  one 
book  which  contains  all  that  a  practitioner  needs  to 
know;  while  the  possessor  of  “Bumstead  on  Vene¬ 
real”  has  no  occasion  to  look  outside  of  its  covers  for 
anything  practical  connected  with  (he  diagnosis,  his¬ 
tory,  or  treatment  of  these  affections. — N.  Y.  Medical 
Journal,  March,  1871. 


pULLERIER  [A.),  and 

Surgeon  to  the  Hdpital  du  Midi. 


TAUMSTEAD  [FREEMAN  J.), 

Professor  of  Venerea  I  Diseases  in  the  College  of 
Physicians  and  Surgeons,  N.  Y. 


AN  ATLAS  OP  VENEREAL  DISEASES.  Translated  and  Edited  by 

Freeman  J.  Bumstead.  In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 
with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 
.  life;  strongly  bound  in  cloth,  $17  00  ;  also,  in  five  parts,  stout  wrappers  for  mailing,  at  $3 
per  part. 

Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  Three  Dol¬ 
lars  a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of  prac¬ 
tice.  G-entlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without  delay. 

A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 


We  wish. for  once  that  our  province  was  not  restrict¬ 
ed  to  methods  of  treatment,  that  we  might  say  some¬ 
thing  of  the  exquisite  colored  plates  in  this  volume. 
— London  Practitioner,  May,  1869. 

As  a  whole,  it  teaches  all  that  can  be  taught  by 
means  of  plates  and  print. — London  Lancet,  March 
13,  1869. 

Superior  to  anything  of  the  kind  ever  before  issued 
on  this  continent. — Canada  Med.  Journal,  March,  ’69. 

The  practitioner  who  desires  to  understand  this 
branch  of  medicine  thoroughly  should  obtain  this, 
the  most  complete  and  best  work  ever  published. — 
Dominion  Med.  Journal,  May,  1869. 

This  is  a  work  of  master  hands  on  both  sides.  M. 
Cul  lerier  is  scarcely  second  to,  we  think  we  may  truly 
say  is  a  peer  of  the  illustrious  and  venerable  Ricord, 
while  in  this  country  we  do  not  hesitate  to  say  that 
Dr.  Bumstead,  as  an  authority,  is  without  a  rival 
Assuring  our  readers  that  these  illustrations  tell  the 
whole  history  of  venereal  disease,  from  its  inception 
to  its  end,  we  do  not  know  a  single  medical  work, 


which  for  its  kind  is  more  nece.ssary  for  them  to  have. 
—Calif  )rnia  Med.  Gazette,  March,  1869. 

The  most  splendidly  illustrated  work  in  the  lan¬ 
guage,  and  in  our  opinion  far  more  useful  than  the 
French  original. — Am.  Journ.  Med.  Sciences,  Jan. ’69. 

The  fifth  and  concluding  number  of  this  magnificent 
work  has  reached  us,  and  we  have  no  hesitation  in 
saying  that  its  illustrations  surpass  those  of  previous 
numbers. — Boston  Med.  and  Surg.  Journal,  Jan.  14, 
1869. 

Other  writers  besides  M.  Cullerier  have  given  ns  a 
good  account  of  the  diseases  of  which  he  treats,  but 
no  one  lias  furnished  us  with  such  a  complete  series 
of  illustrations  of  the  venereal  disea.ses.  There  is, 
however,  an  additional  interest  and  value  possessed 
by  the  volume  before  us  ;  for  it  is  an  American  reprint 
and  translation  of  M,  Cullerier’s  work,  with  inci¬ 
dental  rema  rks  by  one  of  the  most  eminent  American 
syphilographers,  Mr.  Bumstead. — Brit,  and  For. 
Medico- Chir .  Review,  July,  1869. 


JJILL  [BERKELEY], 

Surgeon  to  the  Lock  Hospital,  London. 

ON  SYPHILIS  AND  LOCAL 

one  handsome  octavo  volume  ;  cloth,  $3 

Bringing,  as  it  does,  the  entire  literature  of  the  dis¬ 
ease  down  to  the  present  day,  and  giving  with  great 
ability  the  results  of  modern  research,  it  is  in  every 
respect  a  most  desirable  work,  and  one  which  should 
find  a  place  in  the  library  of  every  surgeon. — Cali¬ 
fornia  Med.  Gazette,  June,  1869. 

Considering  the  scope  of  the  book  and  the  careful 
attention  to  the  manifold  aspects  and  details  of  its 
subject,  it  is  wonderfully  concise.  All  these  qualities 
render  it  an  especially  valuable  book  to  the  beginner. 


CONTAGIOUS  DISORDERS.  In 
!6. 

to  whom  we  would  most  earnestly  recommend  it* 
study  ;  while  it  is  no  less  useful  to  the  practitioner.— 
St.  Louis  Med.  and  Surg.  Journal,  May,  1869. 

The  most  convenient  and  ready  book  of  reference 
we  have  met  with. — N.  Y.  Med.  Record,  May  1,1869. 

Most  admirably  arranged  for  both  student  and  prac¬ 
titioner,  no  other  work  on  the  subject  equals  it ;  it  is 
more  simple,  more  easily  studied. — Buffalo  Med.  and 
Surg.  Journal,  March,  1869. 


^EISSL  (H.),  M.D. 

A  COMPLETE  TREATISE  ON  VENEREAL  DISEASES.  Trans- 

lated  from  the  Second  Enlarged  German  Edition,  by  Frederick.  Sturgis,  M.D  In  one 
octavo  volume,  with  illustrations.  {Preparing .) 


20 


Henry  C.  Lea’s  Publications — {Diseases  of  the  Skin) 


-^ILSON  ( ERASE  US),  F.R.S. 

OX  DISEASES  OF  THE  SKIX.  With  Illustrations  on  wood.  Sev¬ 
enth  American,  from  the  sixth  and  enlarged  English  edition.  In  one  large  octavo  volume 
of  over  800  pages,  $5. 

A  SERIES  OF  PLATES  ILLFSTRATIXG  “TVILSOX  ON  DIS- 

EASES  OF  THE  SKIN consisting  of  twenty  beautifully  executed  plates,  of  which  thir¬ 
teen  are  exquisitely  colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin, 
and  embracing  accurate  representations  of  about  one  hundred  varieties  of  disease,  most  of 
them  the  size  of  nature.  Price,  in  extra  cloth,  $5  50. 

Also,  the  Text  and  Plates,  bound  in  one  handsome  volume.  Cloth,  $10. 


No  one  treating  skin  diseases  should  be  without 
a  copy  of  this  standard  work. —  Canada  Lancet. 

We  can  safely  recommend  it  to  the  profession  at 
the  best  work  on  the  subject  now  in  existence  ir 
the  English  language. — Medical  Times  and  Ga,zette 

Mr.  Wilson’s  volume  is  an  excellent  digest  of  the 
actual  amount  of  knowledge  of  cutaneous  diseases ; 
it  includes  almost  every  fact  or  opinion  of  importance 
connected  with  the  anatomy  and  pathology  of  the 
skin. — British  and  Foreign  Medical  Review. 

Such  a  work  as  the  one  before  us  is  a  most  capital 


ind  acceptable  help.  Mr.  Wilson  has  long  been  held 
is  high  authority  in  this  department  of  medicine,  and 
his  book  on  diseases  of  the  skin  has  long  been  re¬ 
garded  as  one  of  the  best  text-books  extant  on  the 
:  subject.  The  present  edition  is  carefully  prepared, 

!  and  brought  up  in  its  revision  to  the  present  time.  In 
I  this  edition  we  have  also  included  the  beautiful  series 
of  plates  illustrative  of  the  text,  and  in  the  last  edi¬ 
tion  published  separately.  There  are  twenty  of  these 
plates,  nearly  all  of  them  colored  to  nature,  and  ex¬ 
hibiting  with  great  fidelity  the  various  groups  of 
diseases. — Cincinnati  Lancet. 


THE  SAME  AUTHOR.  - 

THE  STUDENT’S  BOOK  OF  CUTANEOUS  MEDICINE  and  Dis- 

EASES  OF  THE  SKIN.  In  One  very  handsome  royal  12mo.  volume.  $3  50. 


J^ELIGAN  [J.  MOORE),  M.D.,  M.R. LA. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  SKIN. 

Fifth  American,  from  the  second  and  enlarged  Dublin  edition  by  T.  W.  Belcher,  M.  D. 
In  one  neat  royal  12mo.  volume  of  462  pages,  cloth,  $2  25. 


Fully  equal  to  all  the  requirements  of  students  and  j  their  value  justly  estimated;  in  a  word,  the  work  Is 
young  practitioners. — Dublin  Med.  Press.  fully  up  to  the  times,  and  is  thoroughly  stocked  with 

Of  the  remainder  of  the  work  we  have  nothing  be-  *^ost  valuable  information.  New  York  Med.  Record, 
yond  unqualified  commendation  to  oflier.  It  is  so  far  1^“-  1^,  1867. 

the  most  complete  one  of  its  size  that  has  appeared,  '  The  most  convenient  manual  of  diseases  of  the 
and  for  the  student  there  can  be  none  which  can  com-  skin  that  can  be  procured  by  the  student. — Chicago 
pare  with  it  in  practical  value.  All  the  late  disco-  Med.  Journal,  Dec.  1866. 
veries  in  Dermatology  have  been  duly  noticed,  and 


THE  SAME  AUTHOR.  - 

ATLAS  OF  CUTANEOUS  DISEASES.  In  one  beautiful  quarto 


volume,  with  exquisitely  colored  plates,  &c.,  presenting  about  one  hundred  varieties  of 
disease.  Cloth,  $5  50. 


The  diagnosis  of  eruptive  disease,  however,  under 
all  circumstances,  is  very  difilcult.  Nevertheless, 
Dr.  Neligan  has  certainly,  “as  far  as  possible,”  given 
a  faithful  and  accurate  representation  of  this  class  of 
diseases,  and  there  can  be  no  doubt  that  these  plates 
will  be  of  great  use  to  the  student  and  practitioner  in 
drawing  a  diagnosis  as  to  the  class,  order,  and  species 
to  which  the  particular  case  may  belong.  While 
looking  over  the  “Atlas”  we  have  been  induced  to 
examine  also  the  “Practical  Treatise,”  and  we  are 


inclined  to  consider  it  a  very  superior  work,  com¬ 
bining  accurate  verbal  description  with  sound  views 
of  the  pathology  and  treatment  of  eruptive  diseases. 
— Glasgow  Med.  Journal. 

A  compend  which  will  very  much  aid  the  practi¬ 
tioner  in  this  difficult  branch  of  diagnosis.  Taken 
with  the  beautiful  plates  of  the  Atlas,  which  are  re¬ 
markable  for  their  accuracy  and  beauty  of  coloring, 
it  constitutes  a  very  valuable  addition  to  the  library 
of  a  practical  man. — Buffalo  Med.  Journal. 


fJILLIER  [THOMAS),  M.D., 

Physician  to  the  Skin  Department  of  University  College  Hospital,  &c. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

Second  American  Edition.  In  one  royal  12mo.  volume  of  358  pp.  With  Illustrations. 
Cloth,  $2  25. 


We  can  conscientiously  recommend  it  to  the  stu¬ 
dent;  the  style  is  clear  and  pleasant  to  read,  the 
matter  is  good,  and  the  descriptions  of  disease,  with 
the  modes  of  treatment  recommended,  are  frequently 
Illustrated  with  well-recorded  cases. — London  Med. 
Times  and  Gazette,  April  1,  1865. 


It  is  a  concise,  plain,  practical  treatise  on  the  vari¬ 
ous  diseases  of  the  skin  ;  just  such  a  work,  indeed, 
as  was  much  needed,  both  by  medical  students  and 
practitioners.  —  Chicago  M^ical  Exami'ner,  May, 
1865. 


ANDERSON  [McCALL),  M.D., 

Physician  to  the  Dispensary  for  Skin  Diseases,  Glasgow,  &c. 

ON  THE  TREATMENT  OF  DISEASES  OF  THE  SKIN.  With  an 

Analysis  of  Eleven  Thousand  Consecutive  Cases.  In  one  vol.  8vo.  $1.  {Lately  Published.) 


GUERSANT’S  SURGICAL  DISEASES  OF  INFANTS 
AND  CHILDREN.  Translated  by  R.  J.  Dunoli- 
SON,  M.D.  1  vol.  8vo.  Cloth,  $2  50. 


DEWEES  ON  THE  PHYSICAL  AND  MEDICAL 
TREATMENT  OF  CHILDREN.  Eleventh  edition. 
1  vol.  8vo.  of  548  pages.  Cloth,  $2  80. 


Henry  C.  Lea’s  Publications — (Diseases  of  Children), 


SI 


SfMITH  {J.  LE  WIS),  M.  D., 

Professor  of  Morbid  Anatomy  in  the  Bellevue  Hospital  Med.  College,  N.  Y. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OP 

CHILDREN.  Second  Edition,  revised  and  greatly  enlarged.  In  one  handsome  octavo 
volume  of  742  pages,  cloth,  $5;  leather,  $6.  {^Lately  Published.) 

From  the  Preface  to  the  Second  Edition. 

In  presenting  to  the  profession  the  second  edition  of  his  work,  the  author  gratefully  acknow¬ 
ledges  the  favorable  reception  accorded  to  the  first.  He  has  endeavored  to  merit  a  continuance 
of  this  approbation  by  rendering  the  volume  much  more  complete  than  before.  Nearly  twenty 
additional  diseases  have  been  treated  of,  among  which  may  be  named  Diseases  Incidental  to 
Birth,  Rachitis,  Tuberculosis,  Scrofula,  Intermittent,  Remittent,  and  Typhoid  Fevers,  Chorea, 
and  the  various  forms  of  Paralysis.  Many  new  formulae,  which  experience  has  shown  to  be 
useful,  have  been  introduced,  portions  of  the  text  of  a  less  practical  nature  have  been  con¬ 
densed,  and  other  portions,  especially  those  relating  to  pathological  histology,  have  been 
rewritten  to  correspond  with  recent  discoveries.  Every  effort  has  been  made,  however,  to  avoid 
an  undue  enlargement  of  the  volume,  but,  notwithstanding  this,  and  an  increase  in  the  size  of 
the  page,  the  number  of  pages  has  been  enlarged  by  more  than  one  hundred. 

227  West  49th  Street,  New  York,  April,  1872. 

The  work  will  be  found  to  contain  nearly  one-third  more  matter  than  the  previous  edition,  and 
it  is  confidently  presented  as  in  every  respect  worthy  to  be  received  as  the  standard  American 
text-book  on  the  subject. 


Eminently  practical  as  well  as  judicious  in  its 
teachings. — Cincinnati  Lancet  and  06s.,  July,  1S72. 

A  standard  work  that  leaves  little  to  be  desired. — 
Indiana  Journal  of  Medicine,  July,  1872. 

We  know  of  no  book  on  this  subject  that  we  can 
more  cordially  recommend  to  the  medical  student 
and  thepractitioner. — Cincinnati  Clinic,  June  29,  ’72. 


We  regard  it  as  superior  to  any  other  single  work 
on  the  diseases  of  infancy  and  childhood. — Detroit 
Rev.  of  Med.  and  Pharmacy,  Aug.  1872. 

We  confess  to  increased  enthusiasm  in  recommend¬ 
ing  this  second  edition. — St.  Louis  Med.  and  Surg. 
Journal,  Aug.  1872. 


ftONDIE  {D.  FRANCIS),  M.  D. 

^  A  PRACTICAL  TREATISE  ON  THE  DISEASES  OP  CHILDREN. 


Sixth  edition,  revised  and  augmented.  In  one  large  octavo  volume  of  nearly  800  closely- 
printed  pages,  cloth,  $5  25  ;  leather,  $6  25. 


The  present  edition,  which  is  the  sixth,  is  fully  up 
to  the  times  in  the  discussion  of  all  those  points  in  the 
pathology  and  treatment  of  infantile  diseases  which 
have  been  brought  forward  by  the  German  and  French 


teachers.  As  a  whole,  however,  the  work  is  the  best 
^merican  one  that  we  have,  and  in  its  special  adapta¬ 
tion  to  American  practitioners  it  certainly  has  no 
equal.  —  New  York  Med.  Record,  March  2,  1868. 


^EST  {CHARLES),  M.D., 

^  '  Physician  to  the  Hospital  for  Sick  Children,  &c. 

LECTURES  ON  THE  DISEASES  OP  INFANCY  AND  CHILD¬ 
HOOD.  Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.  In  one  large 
and  handsome  octavo  volume  of  678  pages.  Cloth,  $4  50  ;  leather,  $5  50.  {List  Issued.) 

The  continued  demand  for  this  work  on  both  sides  of  the  Atlantic,  and  its  translation  into  Ger¬ 
man,  French,  Italian,  Danish,  Dutch,  and  Russian,' show  that  it  fills  satisfactorily  a  want  exten¬ 
sively  felt  by  the  profession.  There  is  probably  no  man  living  who  can  speak  with  the  authority 
derived  from  a  more  extended  experience  than  Dr.  West,  and  his  work  now  presents  the  results  of 
nearly  2000  recorded  cases,  and  600  post-mortem  examinations  selected  from  among  nearly  40,000 
cases  which  have  passed  under  his  care.  In  the  preparation  of  the  present  edition  he  has  omitted 
much  that  appeared  of  minor  importance,  in  order  to  find  room  for  the  introduction  of  additional 
matter,  and  the  volume,  while  thoroughly  revised,  is  therefore  not  increased  materially  in  size. 

Of  all  the  English  writers  on  the  diseases  ol  chil-  living  authorities  in  the  difficult  department  of  medi- 
dren,  there  is  no  one  so  entirely  satisfactory  to  us  as  cal  science  in  which  he  is  most  widely  known.— 
Dr.  West.  For  years  we  have  held  his  opinion  as  Boston  Med.  and  Surg .  Journal. 

Judicial,  and  have  regarded  him  as  one  of  the  highest 


J^Y  THE  SAME  AUTHOR.  {Lately Issued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 

HOOD;  being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  of  Lon¬ 
don,  in  March,  1871.  In  one  volume,  small  12mo.,  cloth,  $1  00. 


^MITH  [EUSTACE),  M.  D.,  • 

Physician  to  the  Northwest  London  Free  Dispensary  for  Sick  Children. 


A  PRACTICAL  TREATISE  ON  THE 

INFANCY  AND  CHILDHOOD.  Second  American,  from  the  second  revised  and 
English  edition.  In  one  handsome  octavo  volume,  cloth,  $2  50. 


This  is  in  every  way  an  admirable  book.  The 
modest  title  which  the  author  has  chosen  for  i  t  scarce¬ 
ly  conveys  an  adequate  idea  of  the  many  subjects 
upon  which  it  treats.  Wasting  is  so  constant  an  at¬ 
tendant  upon  the  maladies  of  childhood,  that  a  trea¬ 
tise  upon  the  wasting  diseases  of  children  must  neces¬ 
sarily  embrace  the  consideration  of  many  affections 
of  which  it  is  a  symptom  ;  and  this  is  excellently  well 
done  by  Dr.  Smith.  The  book  might  fairly  be  de- 


WASTING  DISEASES  OF 

enlarged 
{Lately  Issued.) 

scribed  as  a  practical  handbook  of  the  common  dis¬ 
eases  of  children,  so  numerous  are  the  affections  con¬ 
sidered  either  collaterally  or  directly.  We  are 
acquainted  with  no  safer  guide  to  the  treatment  of 
children’s  diseases,  and  few  works  give  the  insight 
into  the  physiological  and  other  peculiarities  of  chil¬ 
dren  that  Dr.  Smith’s  book  does. — Brit.  Med.Journ., 
April  8,  1871. 


22 


Henry  C.  Lea’s  Publicatioi^s — {Diseases  of  Women) 


^HE  OBSTETRICAL  JOURNAL.  [Free  of  postage  for 

THE  OBSTETRICAL  JOURXAL  of  Oreat  Britain  and  Ireland; 

Including  Midwifery,  and  the  Diseases  of  Women  and  Infants.  With  an  American 
Supplement,  edited  by  William  F.  Jenks,  M.D.  A  monthly  of  about  80  octavo  pages, 
very  handsomely  printed.  Subscription,  Five  Dollars  per  annum.  Single  Numbers,  50 
cents  each. 

Commencing  with  April,  1873,  the  Obstetrical  Journal  consists  of  Original  Papers  by  Brit¬ 
ish  and  Foreign  Contributors  ;  Transactions  of  the  Obstetrical  Societies  in  England  and  abroad  ; 
Reports  of  Hospital  Practice;  Reviews  and  Bibliographical  Notices;  Articles  and  Notes,  Edito¬ 
rial,  Historical,  Forensic,  and  Miscellaneous;  Selections  from  Journals;  Correspondence,  &c. 
Collecting  together  the  vast  amount  of  material  daily  accumulating  in  this  important  and  ra¬ 
pidly  improving  department  of  medical  science,  the  value  of  the  information  which  it  pre¬ 
sents  to  the  subscriber  may  be  estimated  from  the  character  of  the  gentlemen  who  have  already 
promised  their  support,  including  such  names  as  those  of  Drs.  Atthill,  Robert  Barnes,  Henry 
Bennet,  Thomas  Chambers,  Fleetwood  Churchill,  Matthews  Duncan,  Graily  Hewitt, 
Braxton  Hicks,  Alfred  Meadows,  W.  Leishman,  Alex.  Simpson,.  Tyler  Smith,  Edward  J. 
Tilt,  Spencer  Wells,  &c.  <fcc.  ;  in  short,  the  representative  men  of  British  Obstetrics  and  Gynae¬ 
cology. 

In  order  to  render  the  Obstetrical  Journal  fully  adequate  to  the  wants  of  the  American 
profession,  each  number  contains  a  Supplement  devoted  to  the  advances  made  in  Obstetrics  and 
Gynaecology  on  this  side  of  the  Atlantic.  This  portion  of  the  Journal  is  under  the  editorial 
charge  of  Dr.  William  F.  Jenks,  to  whom  editorial  communications,  exchanges,  books  for  re¬ 
view,  &c.,  may  be  addressed,  to  the  care  of  the  publisher. 

Complete  sets  from  the  beginning  can  no  longer  be  furnished,  but  subscriptions  can  com¬ 
mence  with  January,  1875,  or  with  Vol.  II.,  April,  1874. 


tJ^HOMAS  [T.  GAILLARD),M.D., 

Professor  of  Obstetrics,  &e.,  in  the  College  of  Physicians  and  Snrgeons,  N.  Y.,  Sec. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.  Fourth 

edition,  enlarged  and  thoroughly  revised.  In  one  large  and  handsome  octavo  volume  of 
800  pages,  with  191  illustrations.  Cloth,  $5  00;  leather,  $6  00.  {Now  Ready.) 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 
this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  has  been 
received.  Every  portion  has  been  subjected  to  a  conscientious  revision,  and  no  labor  has  been 
spared  to  make  it  a  complete  treatise  on  the  most  advanced  condition  of  its  important  subject. 

A  few  notices  of  the  previous  editions  are  subjoined  ; — 


Profes.sor  Thomas  fairly  took  the  Profession  of  tlie 
United  States  by  storm  when  his  hook  first  made  ifs 
appea’-ance  early  in  1S68.  Its  reception  was  simply 
enthusiastic,  notwithstanding  a  few  adverse  criti¬ 
cisms  from  our  transatlantic  brethren,  the  first  large 
edition  was  rapidly  exhausted,  and  in  six  mouths  a 
second  one  was  issued,  and  in  two  years  a  third  oye 
was  announced  and  published,  and  we  are  now  pro¬ 
mised  the  fourth.  The  popularity  of  this  work  was 
not  ephemeral,  and  its  success  was  unprecedented  in 
the  annals  of  American  medical  literature.  Six  years 
is  a  long  period  in  medical  scientific  research,  but 
Thomas’s  work  on  “Diseases  of  W^'ornen”  is  still  the 
leading  native  production  of  the  United  States.  The 
order,  the  matter,  the  absence  of  theoretical  disputa- 
tiveness,  the  fairness  of  statement,  and  the  elegance 
of  diction,  preserved  throughout  the  entire  range  of 
the  book,  indicate  that  Professor  Thomas  did  not 
overestimate  his  powers  when  he  conceived  the  idea 
and  executed  the  work  of  producing  a  new  treatise 
upon  diseases  of  women. — Prof.  Fallen,  in  Louis¬ 
ville  Med.  Journal,  Sept.  1874. 

Briefly,  we  may  say’ that  we  know  of  no  book 
which  so  completely  and  concisely  represents  the 
present  state  of  gynaecology  ;  none  so  full  of  well- 
digested  and  reliable  teaching  ;  none  which  bespeaks 
an  author  more  apt  in  research  and  abuniant  in  re¬ 
sources. — N.  Y  Med.  Record,  May  1,  1872.  • 

We  should  not  be  doing  our  duty  to  the  profession 
did  we  not  tell  those  who  are  unacquainted  with  the 
book,  how  much  it  is  valued  by  gynaecologists,  and 
how  it  is  in  many  respects  one  of  the  best  text-books  ^ 
on  the  subject  we  possess  in  our  language.  We  have 
no  hesitation  in  recommending  Dr.  Thomas’s  work  as  | 
one  of  the  most  complete  of  its  kind  ever  published,  i 
It  should  be  in  the  possession  of  every  practitioner  [ 
for  reference  and  for  study.— ioncion  Lancet,  April  i 
27,  1872.  I 

We  are  free  to  say  that  we  regard  Dr.  Thomas  the  | 
best  American  authority  on  diseases  of  women. —  ; 
Cincinnati  Lancet  and  Observer,  May,  1872. 


'  No  general  practitioner  can  afford  to  be  without 
it. — St.  Louis  Med.  and  Surg.  Journal,  May,  1872. 

Its  able  author  need  not  fear  compariscAi  between 
it  and  any  similar  work  in  the  English  language; 
nay  more,  as  a  text-boek  for  students  and  as  a  guide 
for  practitioners,  we  believe  it  is  unequalled.  If 
either  student  or  practitioner  can  get  but  one  book 
on  diseases  of  women  that  book  should  be  ‘Thomas.” 
— Amer.  Jour.  Med.  Sciences,  April,  1 872. 

t  To  students  we  unhesitatingly  recommend  it  as 
the  best  text-book  on  diseases  of  females  extant. — 
St  Louis  Med.  Reporter,  June,  1869. 

Of  all  the  army  of  books  thac  nave  appeared  of  late 
years,  on  the  diseases  of  the  uterus  audits  appendages, 
we  know  of  none  thatis  so  clear,  comprehensive,  and 
practical  as  this  of  Dr.  Thomas’,  or  one  that  we  should 
more  emphatically  recommend  to  the  young  practi¬ 
tioner,  as  his  guide. — California  Med.  Gazette,  June, 
1869. 

It  would  be  superfluous  to  give  an  extended  review 
of  what  is  now  firmly  established  as  the  American 
text-book  of  Gynaecology.— N.  1.  Med.  Gazette,  July 
17,  1869. 

This  is  a  new  and  revised  edition  of  a  work  which 
we  recently  noticed  at  some  length,  and  earnestly 
commended  to  the  favorable  attention  of  our  readers. 
The  fact  that,  in  the  short  space  of  one  year,  this 
■second  edition  makes  its  appearance,  shows  that  the 
general  judgment  of  the  profession  has  largely  con¬ 
firmed  the  opinion  we  gave  at  that  time. — Cincinnati 
Lancet,  Aug.  1869. 

It  is  so  short  a  time  since  we  gave  a  full  review  of 
the  first  edition  of  this  book,  that  we  deem  it  only 
necessary  now  to  call  attention  to  the  second  appear¬ 
ance  of  the  work.  Its  success  has  been  remarkable, 
and  we  can  only  congratulate  the  author  on  the 
brilliant  reception  his  book  has  received. — N.  Y.  Med. 
Journal,  April,  1869. 


Henry  C.  Lea^s  Publications — (Diseases  of  Women) 


23 


JJODGE  {HUGH  L.),  M.D., 

Emeritus  Professor  of  Obstetrics,  &c.,  in  the  University  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN;  including  Displacements 

of  the  Uterus.  With  original  illustrations.  Second  edition,  revised  and  enlarged.  In 
one  beautifully  printed  octavo  volume  of  5.31  pages,  cloth,  $4  50. 


From  Prof.  W.  H.  Btford,  of  the  Rush  Medical 
College,  Chicago. 

The  book  bears  the  impress  of  a  master  hand,  and 
must,  as  its  predecessor,  prove  acceptable  to  the  pro¬ 
fession.  In  diseases  of  women  Dr.  Hodge  has  estab¬ 
lished  a  school  of  treatment  that  has  become  world¬ 
wide  in  fame. 

Professor  Hodge’s  work  is  truly  an  original  one 
from  beginning  to  end,  consequently  no  one  can  pe¬ 
ruse  its  pages  without  learning  something  new.  The 
book,  which  is  by  no  means  a  large  one.  is  divided  into 
two  grand  sections,  so  to  speak  :  first,  that  treating  of 
the  nervous  sympathies  of  the  uterus,  and,  secondly. 


hat  which  speaks  of  the  mechanical  treatment  of  di.s- 
placements  of  that  organ.  He  is  disposed,  as  a  non- 
■*eliever  in  the  frequency  of  inflammations  of  the 
uterus,  to  take  strong  ground  against  many  of  the 
highest  authorities  in  this  branch  of  medicine,  and 
the  arguments  which  he  ofi’ers  in  support  of  his  posi¬ 
tion  are,  to  say  the  least,  well  put.  Numerous  wood¬ 
cut.®  adorn  this  portion  of  the  work,  and  add  incalcu¬ 
lably  to  the  proper  appreciation  of  the  variou.-ly 
shaped  instruments  referred  to  by  our  author.  A-  a 
contribution  to  the  study  of  women's  diseases,  it  i>  of 
great  value,  and  is  abundantly  able  to  stand  on  ite 
own  merits. — A.  Y.  Medical  Record,  Sept.  15,  1868. 


'^EST  [CHARLES),  M.D. 

^LECTURES  ON  THE  DISEASES  OF  WOMEN.  Third  American, 

from  the  Third  London  edition.  In  one  neat  octavo  volume  of  about  550  pages,  cloth, 
$3  75  ;  leather,  $4  75. 

seeking  truth,  and  one  that  will  convince  the  student 


As  a  writer.  Dr.  West  stands,  in  our  opinion,  se¬ 
cond  only  to  Watson,  t'ne  “Macaulay  of  Medicine;’ 
he  possesses  that  happy  faculty  of  clothing  instrnc 
tion  in  easy  garments;  combining  pleasure  with 
profit,  he  leads  his  pupils,  in  spite  of  the  ancient  pro¬ 
verb,  along  a  royal  road  to  learning.  His  work  is  one 
which  will  not  satisfy  the  extreme  on  either  side,  but 
It  is  one  that  will  pldase  the  great  majority  who  are 


that  he  has  committed  himself  to  a  candid,  safe,  and 
valuable  guide. — N.  A.  Med.-Chirurg  Revie^o. 

We  have  to  say  of  it,  briefly  and  decidedly,  that  it 
is  the  best  work  on  the  subject  in  any  language,  and 
that  it  stamps  Dr.  West  as  the  facile  princeps  of 
British  obstetric  authors. — Edinburgh  Med.  Journal. 


TPARNES  (ROBERT),  M.  D.,  F.  R.  C.  P., 

Obstetric  Phy.sician  to  St.  Thomas's  Hospital,  &c. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SIJEGI- 

CAL  DISEASES  OP  WOMEN.  In  ono  hnrtdarirne  octavo  volume  of  about  800  pages,  with 
IfiO  illust.rntioTis.  Cloth.  $5  00,  leather,  S6  00.  (Just  Issued.) 

The  very  complete  scope  of  this  volume  and  the  manner  in  which  it  has  been  filled  out,  may 
be  seen  by  the  subjoined  Summary  of  Contents. 

Introduction.  Chapter  I.  Ovaries  ;  Corpus  Luteum.  II.  Fallopian  Tubes.  III.  Shape  of 
Uterine  Cavity.  IV.  Structure  of  Uterus.  V.  The  Vagina.  VI.  Examinations  and  Diagnosis. 
VII.  Significance  of  Leueorrhoea.  VIII.  Discharges  of  Air.  IX.  Watery  Discharges.  X.  Puru¬ 
lent  Discharges.  XI.  Hemorrhagic  Discharges.  XTI  Significance  of  Pain.  XIII.  Significance 
of  Dyspareunia.  XIV.  Significance  of  Sterility.  XV.  Instrumental  Diagnosis  and  Treatment. 
XVI.  Diagnosis  by  the  Touch,  the  Sound,  the  Speculum.  XVII.  Menstruation  and  its  Disor¬ 
ders.  XVIII.  Amenorrhoea.  XIX.  Amenorrhoea  ('continued).  XX.  Dysinenorrhoea.  XXI. 
Ovarian  Dysmenorrhoea,  <tc.  XXII.  Inflammatory  Dysmenorrhoea.  XXIII.  Irregularities  of 
Change  of  Life.  XXIV.  Relations  between  Menstruation  and  Diseases.  XXV.  Disorders  of  O'd 
Age.  XXVI.  Ovary,  Absence  and  Hernia  of.  XXVII.  Ovary,  Hemorrhage,  &c.,  of.  XXVIII. 
Ovary,  Tubercle,  Cancer,  &c.,  of.  XXIX.  Ovarian  Cystic  Tumors.  XXX.  Dermoid  Cysts  of 
Ovary.  XXXI.  Ovarian  Tumors,  Prognosis  of.  XXXII.  Diagnosis  of  Ovarian  Tumors.  XXXIII. 
Ovarian  Cysts,  Treatment  of.  XXXIV.  Fallopian  Tubes.  Diseases  of.  XXXV.  Broad  Liga¬ 
ments,  Diseases  of.  XXXVI.  Extra-uterine  Gestation.  XXXVIT.  Special  Pathology  of  Ute 
rus.  XXXVIII  General  Uterine  Pathology.  XXXIX.  Alterations  of  Blood  Supply.  XL. 
Metritis,  Endometritis,  &c.  XLI.  Pelvic  Cellulitis  and  Peritonitis,  &c.  XLII  Hgematocele,  &o 
XLIII.  Displacements  of  Uterus.  XLIV.  Displacements  (continued).  XLV.  Retroversion  and 
Retroflexion.  XLVI.  Inversion.  XLVII.  Uterine  Tumors.  XLVIII.  Polypus  Uteri.  XLIX. 
Polypus  Uteri  (continued).  L.  Cancer.  LI.  Diseases  of  Vagina.  LII.  Diseases  of  the  Vulva. 


Embodying  the  long  experience  and  personal  obser¬ 
vation  of  one  of  the  greatest  of  living  teachers  in  dis¬ 
eases  of  women,  it  seems  pervaded  by  the  presence 
Oif  the  author,  who  speaks  directly  to  the  reader,  and 
speaks,  too,  as  one  having  authority.  And  yet,  not¬ 
withstanding  this  distinct  personality,  there  is  noth¬ 
ing  narrow  as  to  time,  place,  or  individuals,  in  the 
views  presented,  and  in  the  instructions  given;  Dr. 
Barnes  has  been  an  attentive  student,  not  only  of  Eu¬ 
ropean,  but  also  of  American  literature,  pertaining  to 
diseases  of  females,  and  enriched\his  own  experience 
by  treasures  thence  gathered  ;  he  seems  as  familiar, 
for  example,  with  the  writings  of  Sims,  Emmet,  Tho¬ 


mas,  and  Peaslee,  as  if  these  eminent  men  were  his 
countrymen  and  colleagues,  and  gives  them  a  credit 
which  must  be  gratifying  to  every  American  physi¬ 
cian. — Am  Journ.  Med.  iScl,  April,  1874. 

Throughout  the  whole  book  it  is  impossible  not  to 
feel  that  the  author  has  spontaneously,  conscientious¬ 
ly,  and  fearlessly  performed  his  task.  He  goes  direct 
to  the  point,  and  does  not  loiter  on  the  way  to  gossip 
or  quarrel  with  other  authors.  Dr.  Barnes’s  book 
will  be  eagerly  read  all  over  the  world,  and  will 
everywhere  be  admired  for  its  comprehensiveness, 
honesty  of  purpose,  and  ability  — The  Obstet.  Journ. 
of  Great  Britain  and  Ireland,  March,  1874. 


CHURCHILL  ON  THE  PUERPERAL  FEVER  AND 
OTHER  DISEASES  PECULIAR  TO  WOMEN.  1  vol. 
8vo.,  pp.  450,  cloth.  $2  50. 

MEIGS  ON  WOMAN:  HER  DISEASES  AND  THEIR 
REMEDIES.  A  Series  of  Lectures  to  his  Class. 
Fourth  and  Improved  Edition.  1  vol.  Svo.,  over 
700  pages,  cloth,  .$5  00  ;  leather,  *6  00. 

MEIGS  ON  THE  NATURE,  SIGNS,  AND  TREAT¬ 
MENT  OF  CHILDBED  FEVER.  1  vol.  8vo.,  pp. 
365,  cloth.  $2  00. 


'  ASHWELL’S  PRACTICAL  TREATISE  ON  THE  DIS¬ 
EASES  PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  London  edition.  1  vol. 
8vo.,  pp.  528,  cloth.  -$3  50. 

I  DEWEES’S  TREATISE  ON  THE  DISEASES  OF  FE¬ 
MALES.  With  illustrations.  Eleventh  Edition, 

I  with  the  Author’s  last  improvements  and  correc- 
!  tions.  In  one  octavo  volume  of  636  pages,  with 
plates,  cloth.  $3  00. 


24 


Henry  C.  Lea’s  Publications — {Midwifery) 


TTODGE  [HUGH  L.),  M.D., 

Emeritus  Professor  of  Midwifery,  &c. ,  in  the  University  of  Pennsylvania,  &c. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  Illus¬ 
trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 

The  work  of  Dr.  Hodge  is  something  more  than  a 
simple  presentation  of  his  particular  views  in  the  de¬ 


partment  of  Obstetrics;  it  is  something  more  than  an  | 
ordinary  treatise  on  midwifery  ;  it  is,  in  fact,  a  cyclo- 1 
psedia  of  midwifery.  He  has  aimed  to  embody  in  a  ' 
single  volume  the  whole  science  and  art  of  Obstetrics. 
An  elaborate  text  is  combined  with  accurate  and  va¬ 
ried  pictorial  illustrations,  so  that  no  fact  or  principle 
Is  left  unstated  or  unexplained. — Am.  Med.  Times, 
Sept.  3,  1864. 

We  should  like  to  analyze  the  remainder  of  this 
excellent  work,  but  already  has  this  review  extended 
beyond  our  limited  space.  We  cannot  conclude  this! 
notice  without  referring  to  the  excellent  finish  of  the  ■ 
work.  In  typography  it  is  not  to  be  excelled  ;  the 
paper  is  superior  to  what  is  usually  aflTorded  by  our 
American  cousins,  quite  equal  to  the  best  of  English 
books.  The  engravings  and  lithographs  are  most! 
beautifully  executed.  The  work  recommends  itself; 
for  its  originality,  and  is  in  every  way  a  most  vain- 1 
able  addition  to  those  on  the  subject  of  obstetrics. —  i 
Canada  Med.  Journal,  Oct.  1864.  I 

It  is  very  large,  profusely  and  elegantly  illustrated,  i 
and  is  fitted  to  take  its  place  near  the  works  of  great 
obstetricians.  Of  the  American  works  on  the  subject! 
It  is  decidedly  the  best. — Edinb.  Med.  Jour.,  Dec.  '64.1 


We  have  examined  Professor  Hodge’s  work  with 
great  satisfaction  ;  every  topic  is  elaborated  most 
fully.  The  views  of  the  author  are  comprehensive, 
and  concisely  stated.  The  rules  of  practice  are  judi¬ 
cious,  and  will  enable  the  practitioner  to  meet  every 
emergency  of  obstetric  complication  with  confidence. 
— Chicago  Med.  Journal,  Aug.  1864. 

More  time  than  we  have  had  at  our  disposal  since 
we  received  the  great  work  of  Dr.  Hodge  is  necessary 
to  do  it  justice.  It  is  undoubtedly  by  far  the  most 
original,  complete,  and  carefully  composed  treatise 
on  the  principles  and  practice  of  Obstetrics  which  has 
ever  been  issued  from  the  American  press. — Pacific 
Med.  and  Surg.  Journal,  July,  1864. 

We  have  read  Dr.  Hodge’s  book  with  great  plea¬ 
sure,  and  have  much  satisfaction  in  expressing  our 
commendation  of  it  as  a  whole.  It  is  certainly  highly 
instructive,  and  in  the  main,  we  believe,  correct.  The 
great  attention  which  the  author  has  devoted  to  the 
mechanism  of  parturition,  taken  along  with  the  con¬ 
clusions  at  which  he  has  arrived,  point,  we  think, 
conclusively  to  the  fact  that,  in  Britain  at  least,  the 
doctrines  of  Naegele  have  been  too  blindly  received. 
— Glasgow  Med.  Journal,  Oct.  1864. 


***  Specimens  of  tlie  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 


rpANNER  [THOMAS  H),  M.D. 

ON  THE  SIGNS  AN!)  DISEASES  OF  PREGNANCY.  First  American 

from  the  Second  and  Enlarged  English  Edition.  With  four  colored  plates  and  illustrations 
on  wood.  In  one  handsome  octavo  volume  of  about  500  pages,  cloth,  $4  25. 


The  very  thorough  revision  the  work  has  undergone 
has  added  greatly  toils  practical  value,  and  increased 
materially  its  efficiency  as  a  guide  to  the  student  and 
to  the  young  practitioner. — Am.  Journ.  Med.  Sci., 
April,  1868. 

With  the  immense  variety  of  subjects  treated  of 
and  the  ground  which  they  are  made  to  cover,  the  im¬ 
possibility  of  giving  an  extended  review  of  this  truly 
remarkable  work  must  be  apparent.  We  have  not  a 
single  fault  to  find  with  it,  and  most  heartily  com¬ 
mend  it  to  the  careful  study  of  every  physician  who 
would  not  only  always  be  sure  of  his  diagno.sis  of 


pregnancy,  but  always  ready  to  treat  all  the  nume¬ 
rous  ailments  that  are,  unfortunately  for  the  civilized 
women  of  to-day,  so  commonly  associated  with  the 
function. — N.  Y.  Med.  Record,  March  16,  1868. 

We  recommend  obstetrical  students,  young  and 
old,  to  havt  this  volume  in  their  collections.  It  con¬ 
tains  not  only  a  fair  statement  of  the  signs,  symptoms, 
and  diseases  of  pregnancy,  but  comprises  in  addition 
much  interesting  relative  matter  that  is  not  to  be 
found  in  any  other  work  that  we  can  name. — Edin¬ 
burgh  Med  Journal,  Jan.  1868. 


[JOSEPH  GRIFFITHS),  M.  D., 

Physician- Accoucheur  to  the  British  General  Hospital,  &c. 

OBSTETRIC  APHORISMS  FOR  THE  HSE  OP  STUDENTS  COM- 


MENCING  MIDWIFERY  PRACTICE.  Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  Hutchins,  M.  D.  With  Illustrations.  In  one 
neat  12mo.  volume.  Cloth,  $1  25.  {Lately  Issued.) 

*  See  p.  3  of  this  Catalogue  for  the  terms  on  which  this  work  is  offered  as  a  premium  to 
subscribers  to  the  “American  Journal  of  the  Medical  Sciences.” 


It  is  really  a  capital  little  compendium  of  the  sub¬ 
ject,  and  we  recommend  young  practitioners  to  buy  it 
and  carry  it  with  them  when  called  to  attend  cases  of 
labor.  They  can  while  away  the  otherwise  tedious 
hours  of  waiting,  and  thoroughly  fix  in  their  memo¬ 
ries  the  most  important  practical  suggestions  it  con¬ 
tains.  The  American  editor  has  materially  added  by 
his  notes  and  the  concluding  chapters  to  the  com¬ 
pleteness  and  general  value  of  the  book. — Chicago 
Med.  Journal,  Feb.  1870. 

The  manual  before  us  containsin  exceedingly  small 
compass — small  enough  to  carry  in  the  pocket — about 
all  there  is  of  obstetrics,  condensed  into  a  nutshell  of 
Aphorisms.  The  illustrations  are  well  selected,  and 
serve  as  excellent  reminders  of  the  conduct  of  labor — 
regular  and  difficult. — Cincinnati  Lancet,  April,  ’70. 

'•’his  is  a  mostadmirablelittle  work,  and  completely 


answers  the  purpose.  It  is  not  only  valuable  for 
young  beginners,  but  no  one  who  is  not  a  proficient 
in  the  art  of  obstetrics  should  be  without  it,  because 
it  condenses  all  that  is  necessary  to  know  for  ordi¬ 
nary  midwifery  practice.  We  commend  the  book 
most  favorably. — St.  Louis  Med.  and  Surg.  Journal, 
Sept.  10,  1870. 

A  studied  perusal  of  this  little  book  has  satisfied 
us  of  its  eminently  practical  value.  The  object  of  the 
work,  the  author  says,  in  his  preface,  is  to  give  the 
student  a  few  brief  and  practical  directions  respect¬ 
ing  the  management  of  ordinary  cases  of  labor  ;  and 
also  to  point  out  to  him  in  extraordinary  cases  when 
and  how  he  may  act  upon  his  own  responsibility,  and 
when  he  ought  to  send  for  assistance. — N.  Y.  Medical 
Journal,  May,  1870. 


'^INCKEL  [F.), 

”  '  Professor  and  Director  of  the  Gynaecological  Clinic  in  the  University  of  Rostock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 

MENT  OF  CHILDBED,  for  Students  and  Practitiofiers.  Translated,  with  the  consent  of 
the  author,  from  the  Second  German  Edition,  by  James  Read  Chadwick,  M.D.  In  one 
octavo  volume.  {Preparing.) 


Henry  C.  Lea’s  Publications — {Midwifery) 


25 


TEISHMAN  [WILLIAM),  M.D., 

Regius  Professor  of  Midwifery  in  the  University  of  Glasgow,  &c. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF 

PREGNANCY  AND  THE  PUERPERAL  STATE.  In  one  large  and  very  handsome  oc¬ 
tavo  volume  of  over  700  pages,  with  one  hundred  and  eighty-two  illustrations.  Cloth, 
$5  00;  leather,  $6  00.  (Lately  Fttblished.) 


This  is  one  of  a  most  complete  and  exhaustive  cha¬ 
racter.  We  have  gone  carefully  through  it,  and  there 
is  no  subject  in  Obstetrics  which  has  not  been  con¬ 
sidered  well  and  fully.  The  result  is  a  work,  not 
only  admirable  as  a  text-hook,  but  valuable  as  a  work 
of  reference  to  the  practitioner  in  the  various  emer¬ 
gencies  of  obstetric  practice.  Take  it  all  in  all,  we 
have  no  hesitation  in  saying  that  it  is  in  our  judgment 
the  best  Eoglish  work  on  the  subject. — London  Lan¬ 
cet,  Aug.  2d,  1873. 

The  work  of  Leishman  gives  an  excellent  view  of 
modern  midwifery,  and  evinces  its  author’s  extensive 
acquaintance  with  British  and  foreign  literature  ;  and 
not  only  acquaintance  with  it,  but  wholesome  diges¬ 
tion  and  sound  judgment  of  it.  He  has,  withal,  a 
manly,  free  style,  and  can  state  a  difficult  and  compli¬ 
cated  matter  with  remarkable  clearness  and  brevity. 
— Edin.  Med.  Journ.,  Sept.  1873. 

The  author  has  succeeded  in  presenting  to  the  pro¬ 
fession  an  admirable  treatise,  especially  in  its  practi¬ 
cal  aspects  ;  one  which  is,  in  general,  clearly  written, 
and  sound  in  doctrine,  and  one  which  cannot  fail  to 
add  to  his  already  high  reputation.  In  concluding 
our  examination  of  this  work,  we  cannot  avoid  again 
saying  that  Dr.  Leishman  has  fully  accomplished 
that  difficult  task  of  presenting  a  good  text-book  upon 
obstetrics.  We  know  none  better  for  the  use  of  the  stu¬ 
dent  or  junior  practitioner. — Am.  Practitioner,  Mar. 
1874. 

It  proposes  to  offer  to  practitioners  and  students 


“A  Complete  System  of  the  Midwifery  of  the  Present 
Day,”  and  well  redeems  the  promise.  In  all  that 
relates  to  the  subject  of  labor,  the  teaching  is  admi¬ 
rably  clear,  concise,  and  practical,  representing  not 
alone  British  practice,  but  the  contributions  of  Con¬ 
tinental  and  American  schools. — N.  Y.  Med.  Record, 
March  2,  1874. 

The  work  of  Dr.  Leishman  is,  in  many  respects, 
not  only  the  best  treatise  on  midwifery  that  we  have 
seen,  but  one  of  the  best  treatises  on  any  medical  sub¬ 
ject  that  has  been  published  of  late  years. — Land. 
Practitioner,  Feb.  1874. 

It  was  written  to  supply  a  desideratum,  and  we  will 
be  much  surprised  if  it  does  not  fulfil  the  purpose  of 
its  author.  Taking  it  as  a  whole,  we  know  of  no 
work  on  obstetrics  by  an  English  author  in  which  the 
student  and  the  practitioner  will  find  the  information 
so  clear  and  so  completely  abreast  of  the  present  state 
of  our  knowledge  on  the  v,\xbieci.— Glasgow  Med. 
Journ.,  Aug.  1873. 

Dr.  Leishman’s  System  of  Midwifery,  which  has 
only  just  been  published,  will  go  far  to  supply  the 
want  which  has  so  long  been  felt,  of  a  really  good 
modern  English  text-book.  Although  large,  as  is  in¬ 
evitable  in  a  work  on  so  extensive  a  subject,  it  is  so 
well  and  clearly  written,  that  it  is  never  wearisome 
to  read.  Dr.  Leishman’s  work  may  be  confidently 
recommended  as  an  admirable  text-book,  and  is  sure 
to  be  largely  used. — Lond.  Med.  Record,  Sept.  1873. 


J^AMSBOTHAM  [FRANCIS  H.),  M.D.  ‘ 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI- 


CINE  AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  &c.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  large 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 


all  nearly  200  large  and  beautiful  figures. 

We  will  only  add  that  the  student  will  learn  from 
it  all  he  need  to  know,  and  the  practitioner  will  find 
it,  as  a  book  of  reference,  surpassed  by  none  other. — 
Stethoscope. 

The  character  and  merits  of  Dr.  Ramsbotham’s 
work  are  so  well  known  and  thoroughly  established, 
that  comment  is  unnecessary  and  praise  superfluous. 
The  illustrations,  which  are  numerous  and  accurate, 
are  executed  in  the  highest  style  of  art.  We  cannot 
too  highly  recommend  the  work  to  our  readers. — St. 
Louis  Med.  and  Surg.  Journal. 


$7  00. 

To  the  physician’s  library  it  is  indispensable,  while 
to  the  student,  as  a  text-book,  from  which  to  extract 
the  material  for  laying  the  foundation  of  an  education 
on  obstetrical  science,  it  has  no  superior. — Ohio  Med. 
and  Surg.  Journal. 

When  we  call  to  mind  the  toil  we  underwent  in 
acquiring  a  knowledge  of  this  subject,  we  cannot  but 
envy  the  student  of  the'present  day  the  aid  which 
this  work  will  afford  him. — Am.  Jour,  of  the  Med. 
Sciences. 


QHURCHILL  [FLEETWOOD),  M.D.,  M.R.I.A. 

ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.  A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additions 
by  D.  Francis  Condie,  M.  D.,  author  of  a  “Practical  Treatise  on  the  Diseases  of  Chil¬ 
dren,”  &c.  With  one  hundred  and  ninety-four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.  Cloth,  $4  00;  leather,  $5  00. 


These  additions  render  the  work  still  more  com¬ 
plete  and  acceptable  than  ever ;  and  we  can  com¬ 
mend  it  to  the  profession  with  great  cordiality  and 
pleasure. — Cin-iinnati  Lancet. 

Few  works  on  this  branch  of  medical  science  are 
equal  to  it,  certainly  none  excel  it,  whether  in  regard 
to  theory  or  practice — Brit.  Am.  Journal. 

No  treatise  on  obstetrics  with  which  we  are  ac¬ 


quainted  can  compare  favorably  with  this,  in  re' 
spect  to  the  amount  of  material  which  has  been  gath¬ 
ered  from  every  source. — Boston  Med.  and  Surg. 
Journal. 

There  is  no  better  text-book  for  students,  or  work 
of  reference  and  study  for  the  practising  physician 
than  this.  It  should  adorn  and  enrich  every  medical 
library. — Chicago  Med.  Journal. 


MONTGOMERY’S  EXPOSITION  OF  THE  SIGNS  i  SIGBT’S  SYSTEM  OF  MIDWIFERY.  With  Notes 
AND  SYMPTOMS  OF  PREGNANCY.  With  two  !  and  Additional  Illustrations.  Second  American 
exquisite  colored  plates,  and  numerous  wood-cuts,  j  edition.  One  volume  octavo,  cloth,  422  pages. 
In  1  vol.  8vo.,  of  nearly  600  pp.,  cloth.  $3  75.  i  $2  60. 


26 


Henry  C.  Lea’s  Fublioations—- (iSwrgfery) 


/^ROSS  {SAMUEL  D.),  M.D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 


A  SYSTEM  OF  SURGERY:  Pathological,  Diagnostic,  Therapeutic, 

and  Operative.  Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.  Fifth  edition, 
carefully  revised,  and  improved.  In  two  large  and  beautifully  printed  imperial  octavo  vol¬ 
umes  of  about  2300  pages,  strongly  bound  in  leather,  with  raised  bands,  $16.  {Just  Issued.) 

The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.  In  the 
present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully  up  to 
the  day.  To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  enlarged  by 
nearly  one-fourth,  notwithstanding  which  the  price  has  been  kept  at  its  former  very  moderate 
rate.  By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  ol  matter  is 
condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary  octavos. 
This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  binding,  renders 
it  one  of  the  cheapest  works  accessible  to  the  profession.  Every  subject  properly  belonging  to  the 
domain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this  work  may  be  said  to 
have  in  it  a  surgical  library.  A  few  notices  of  the  previous  edition  are  subjoined  ; — 


It  must  long  remain  the  most  comprehensive  work 
on  this  important  part  of  medicine. — Boston  Medical 
and  SurgicalJournal,  March  23,  1865. 

We  have  compared  it  with  most  of  our  standard 
works,  such  as  those  of  Erichsen,  Miller,  Fergusson, 
Syme,  and  others,  and  we  must,  in  justice  to  our 
author,  award  it  the  pre-eminence.  As  a  work,  com¬ 
plete  in  almost  every  detail,  no  matter  how  minute 
or  trifling,  and  embracing  every  subject  known  in 
the  principles  and  practice  of  surgery,  we  believe  it 
stands  without  a  rival.  Dr.  Gross,  in  his  preface,  re¬ 
marks  “my  aim  has  been  to  embrace  the  whole  do¬ 
main  of  surgery,  and  to  allot  to  every  subject  its 
legitimate  claim  to  notice;”  and,  we  assure  our 
reader.s,  he  has  kept  his  word.  It  is  a  work  which 
we  can  most  confidently  recommend  to  our  brethren, 
for  its  utility  is  becoming  the  more  evident  the  longer 
it  is  upon  the  shelves  of  our  library.— Gawada  Med. 
Journal,  September,  1865. 

The  first  two  editions  of  Professor  Gross’  Systeih  of 
Surgery  are  so  well  known  to  the  profession,  and  so 
highly  prized,  that  it  would  be  idle  for  us  to  speak  in 
praise  of  this  work. —  Chicago  Medical  Journal, 
September,  1865. 

We  gladly  indorse  the  favorable  recommendation 
of  the  work,  both  as  regards  matter  and  style,  which 
we  made  when  noticing  its  first  appearance.  British 
and  Foreign  Medico-Chirurgical  Review,  Oct.  1865. 

The  most  complete  work  that  has  yet  issued  from 
the  press  on  the  science  and  practice  of  surgery. — 
London  Lancet. 

This  system  of  surgery  is,  we  predict,  destined  to 
take  a  commanding  position  in  our  surgical  litera¬ 
ture,  and  be  the  crowning  glory  of  the  author’s  well 
earned  fame.  As  an  authority  on  general  surgical 
subjects,  this  work  is  long  to  occupy  a  pre-eminent 
place,  not  only  at  home,  but  abroad.  We  have  no 


hesitation  in  pronouncing  it  without  a  rival  in  our 
language,  and  equal  to  the  best  systems  of  surgery  in 
any  language. — N.  Y.  Med.  Journal. 

Not  only  by  far  the  best  text-book  on  the  subject, 
as  a  whole,  within  the  reach  of  American  students, 
but  one  which  will  be  much  more  than  ever  likely 
to  be  resorted  to  and  regarded  as  a  high  authority 
abroad. — Am.  Journal  Med.  Sciences,  Jan.  1865. 

The  work  contains  everything,  minor  and  major, 
operative  and  diagnostic,  including  mensuration  and 
examination,  venereal  diseases,  and  uterine  manipu¬ 
lations  and  operations.  It  is  a  complete  Thesaurus 
of  modern  surgery,  where  the  student  and  practi¬ 
tioner  shall  nut  seek  in  vain  for  what  they  desire.™ 
San  Francisco  Med.  Press,  Jan.  1865. 

Open  it  where  we  may,  we  find  sound  practical  in¬ 
formation  conveyed  in  plain  language.  This  book  ie 
no  mere  provincial  or  even  national  system  of  sur¬ 
gery,  but  a  work  which,  while  very  largely  indebted 
to  the  past,  has  a  strong  claim  on  the  gratitude  of  the 
future  of  surgical  science. — Edinburgh  Med.  Journal, 
Jan.  1865. 

A  glance  at  the  work  is  sufficient  to  show  that  the 
author  and  publisher  have  spared  no  labor  in  making 
it  the  most  complete  “System  of  Surgery”  ever  pub¬ 
lished  in  any  country. — St.  Louis  Med.  and  Surg. 
Journal,  April,  1865. 

A  system  of  surgery  which  we  think  unrivalled  in 
our  language,  and  which  will  indelibly  associate  his 
name  with  surgical  science.  And  what,  in  our  opin¬ 
ion,  enhances  the  value  of  the  wora  is  that,  while  the 
practising  surgeon  will  find  all  that  he  requires  in  it, 
it  is  at  the  same  time  one  of  the  most  valuable  trea¬ 
tises  which  can  be  put  into  the  hands  of  the  student 
seeking  to  know  the  principles  and  practice  of  thi* 
branch  of  the  profession  which  he  designs  subse¬ 
quently  to  follow.  — The  Brit.  Am.Journ.,  Montreal. 


B 


Y  TEE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE 

AIR-PASSAGES.  In  1  vol.  8vo.,  with  illustrations,  pp.  468,  cloth,  $2  76. 


SKEf’S  OPERATIVE  SURGERY.  In  1  vol.  8vo.  GIBSON’S  INSTITUTES  AND  PRACTICE  OF  SUR- 
cloth  of  over  650  pages  ;  with  about  100  wood-cuts.  gery.  Eighth  edition,  improved  and  altered.  'With 
ajj  2,5’  thirty-four  plates.  In  two  handsome  octavo  vei- 

COOPER’S  LECTURES  ON  THE  PRINCIPLES  AND  umes,  about  1000  pp., leather, raised  bandt.  $6  50. 
Pkacticeof  Surgery.  In  1  vol.  8vo.  cloth,  750p.  $2.  | 

JIULLER  {JAMES), 

111  Late  Professor  of  Surgery  in  the  University  of  Edinburgh,  &c. 

PRINCIPLES  OF  SURGERY.  Fourth  American,  from  the  third  and 

revised  Edinburgh  edition.  In  one  large  and  very  beautiful  volume  of  700  pages,  with 
two  hundred  and  forty  illustrations  on  wood,  cloth,  $3  75. 

j^Y  THE  SAME  AUTHOR.  - 

THE  PRACTICE  OF  SURGERY.  Fourth  American,  from  the  last 

Edinburgh  edition.  Revised  by  the  American  editor.  Illustrated  by  three  hundred  and 
sixty-four  engravings  on  wood.  In  one  large  octavo  volume  of  nearly  700  pages,  cloth, 
$3  75. _ 

^ARGENT  {F.  TU.),  M.D. 

^  ON  BANDAGING  AND  OTHER  OPERATIONS  OF  MINOR 

SURGERY,  New  edition,  with  an  additional  chapter  on  Military  Surgery.  One  handsome 
royal  l2mo.  volume,  of  nearly  400  pages,  with  184  wood-cuts.  Cloth,  $1  76. 


Henry  C.  Lea’s  Publications — (Surgery). 


27 


ASHHURST  {JOHN,  Jr.),  M.D., 

Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

THE  PRIXCIPLES  AXD  PRACTICE  OF  SURGERY.  In  one 

very  large  and  handsome  octavo  volume  of  about  1000  pages,  with  nearly  550  illustrations, 
cloth,  $6  50;  leather,  raised  bands,  $7  50.  {Lately  Published.) 

The  object  of  the  author  has  been  to  present,  within  as  condensed  a  compass  as  possible,  a 
complete  treatise  on  Surgery  in  all  its  branches,  suitable  both  as  a  text-book  fbr  the  student  and 
a  work  of  reference  for  the  practitioner.  So  much  has  of  late  years  been  done  for  the  advance¬ 
ment  of  Surgical  Art  and  Science,  that  there  seemed  to  be  a  want  of  a  work  which  should  present 
the  latest  aspects  of  every  subject,  and  which,  by  its  American  character,  should  render  accessible 
to  the  profession  at  large  the  experience  of  the  practitioners  of  both  hemispheres.  This  has  been 
the  aim  of  the  author,  and  it  is  hoped  that  the  volume  will  be  found  to  fulfil  its  purpose  satisfac¬ 
torily.  The  plan  and  general  outline  of  the  work  will  be  seen  by  the  annexed 

CONDENSED  SUMMARY  OE  CONTENTS. 


Chapter  I.  Inflammation.  II.  Treatment  of  Inflammation.  III.  Operations  in  general; 
Anaesthetics.  IV.  Minor  Surgery.  V.  Amputations.  VI.  Special  Amputations.  VII.  Effects 
of  Injuries  in  General  :  Wounds.  VIII.  Gunshot  Wounds.  IX.  Injuries  of  Bloodvessels.  X. 
Injuries  of  Nerves,  Muscles  and  Tendons,  Lymphatics,  Bursae,  Bones,  and  Joints.  XI.  Fractures. 
XII.  Special  Fractures.  XIII.  Dislocations.  XIV.  Effects  of  Heat  and  Cold.  XV.  Injuries 
of  the  Head.  XVI.  Injuries  of  the  Back.  XVII.  Injuries  of  the  Face  and  Neck.  XVIII. 
Injuries  of  the  Chest.  XIX.  Injuries  of  the  Abdomen  and  Pelvis.  XX.  Diseases  resulting  from 
Inflammation.  XXI.  Erysipelas.  XXII.  Pyaemia.  XXIII.  Diathetic  Diseases  :  Struma  (in¬ 
cluding  Tubercle  and  Scrofula) ;  Rickets.  XXIV.  Venereal  Diseases  ;  Gonorrhoea  and  Chancroid. 
XXV.  Venereal  Diseases  continued  :  Syphilis.  XXVI.  Tumors.  XXVII.  Surgical  Diseases  of 
Skin,  Areolar  Tissue,  Lymphatics,  Muscles,  Tendons,  and  Bursae.  XXVIII.  Surgical  Disease 
of  Nervous  System  (including  Tetanus).  XXIX.  Surgical  Diseases  of  Vascular  System  (includ¬ 
ing  Aneurism).  XXX.  Diseases  of  Bone.  XXXI.  Diseases  of  Joints.  XXXII.  Excisions. 
XXXIII.  Orthopaedic  Surgery.  XXXIV.  Diseases  of  Head  and  Spine.  XXXV.  Diseases  of  the 
Eye.  XXXVI.  Diseases  of  the  Ear.  XXXVII.  Diseases  of  the  Face  and  Neck.  XXXVIII. 
Diseases  of  the  Mouth,  Jaws,  and  Throat.  XXXIX.  Diseases  of  the  Breast.  XL.  Hernia.  XLI. 
Special  Hernias.  XLII.  Diseases  of  Intestinal  Canal.  XLIII.  Diseases  of  Abdominal  Organs, 
and  various  operations  on  the  Abdomen.  XLIV.  Urinary  Calculus.  XLV.  Diseases  of  Bladder 
and  Prostate.  XLVI.  Diseases  of  Urethra.  XLVII.  Diseases  of  Generative  Organs.  Index. 


Its  author  has  evidently  tested  the  writings  and 
experiences  of  the  past  and  present  in  the  crucible 
of  a  careful,  analytic,  and  honorable  mind,  and  faith¬ 
fully  endeavored  to  bring  his  work  up  to  the  level  of 
the  highest  standard  of  practical  surgery.  He  is 
frank  and  definite,  and  gives  us  opinions,  and  gene¬ 
rally  sound  ones,  instead  of  a  resume  of  the 

opinions  of  others.  He  is  conservative,  but  not  hide¬ 
bound  by  authority.  His  style  is  clear,  elegant,  and 
scholarly.  The  wc  rk  is  an  admirable  tex-tbook,  and 
a  useful  book  of  reference  It  is  a  credit  to  Ameiican 
professional  literature,  and  one  of  the  first  ripe  fruits 
of  the  soil  fertilized  by  the  blood  of  our  late  unhappy 
war. — N.  Y.  Med.  Record,  Feb.  1,  1S72. 


Indeed,  the  work  as  a  whole  must  be  regarded  as 
an  excellent  and  concise  exponent  of  modern  sur¬ 
gery,  and  as  such  it  will  be  found  a  valuable  text¬ 
book  for  the  student,  and  a  useful  book  of  reference 
for  the  general  practitioner. — N.  Y.  Med.  Journal, 
Feb.  1572. 

I  It  gives  ns  great  pleasure  to  call  the  attention  of  the 
I  profession  to  this  excellent  work.  Our  knowledge  of 
its  talented  and  accomplished  author  led  us  to  expect 
from  him  a  very  valuable  treatise  upon  subjects  to 
which  he  has  repeatedly  given  evidence  of  having  pro- 
!  fitably  devoted  much  time  and  labor,  and  we  are  in  no 
I  way  disappointed.— PhiZa.  Med.  Times,  Feb.  1, 1872. 


PIRRIE  ( WILLIAM),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE  PRIXCIPLES  AXD  PRACTICE  OF  SURGERY.  Edited  by 

John  Neill,  M,  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  to  the 
Pennsylvania  Hospital,  <fec.  In  one  very  handsome  octavo  volume  of  780  pages,  with  316 
illustrations,  cloth,  $3  75. 


IJAMILTON  {FRANK  H),  M.D., 

Professor  of  Fractures  and  Dislocations,  Ac.,  in  BeUevue  Hosp.  Med.  College,  New  York. 

A  PRACTICAL  TREATISE  ON  FRACTURES  AND  DISLOCA- 

TIONS.  Fourth  edition,  thoroughly  revised.  In  one  large  and  handsome  octavo  volume 
ot  nearly  800  pages,  with  several  hundred  illustrations.  Cloth,  $5  75;  leather,  $6  75. 


It  is  not,  oL  course,  our  intention  to  review  in  ex- 
tenso,  Hamilton  on  “Fractures  and  Dislocations.” 
Eleven  years  ago  such  review  might  not  have  been 
out  of  place  ;  to-day  the  work  is  an  authority,  so  well, 
so  generally,  and  so  favorably  known,  that  it  only 
remains  for  the  reviewer  to  say  that  a  new  edition  is 
just  out,  and  it  is  better  than  either  of  its  predeces¬ 
sors. — Cincinnati  Clinic,  Oct.  14,  1871. 

Undoubtedly  the  best  work  on  Fractures  and  Dis¬ 
locations  in  the  English  language. — Cincinnati  Med. 
Repertory,  Oct.  1871. 

We  have  once  more  before  us  Dr. .Hamilton’s  admi¬ 


rable  treatise,  which  we  have  always  considered  the 
most  complete  and  reliable  work  on  the  subject.  As 
a  whole,  the  work  is  without  an  equal  in  the  litera¬ 
ture  of  the  profession. — Boston  Med.  and  Surg. 
Journ.,  Oct.  12,  1871. 

It  is  unnecessary  at  this  time  to  commend  the  book, 
except  to  such  as  are  beginners  in  the  study  of  this 
particular  branch  of  surgery.  Every  practical  sur¬ 
geon  in  this  country  and  abroad  knows  of  it  as  a  most 
trustworthy  guide,  and  one  which  they,  in  common 
with  us,  would  unqualifiedly  recommend  as  the  high¬ 
est  authority  in  any  language. — N.  Y.  Med.  Record, 
Oct.  16,  1871. 


28 


Henry  C.  Lea’s  Publications — {Surgery). 


f^RICHSEN  {JOHN  E.), 

Professor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIEXCE  AXD  ART  OF  SURGERY;  being  a  Treatise  on  Sur¬ 
gical  Injuries,  Diseases,  and  Operations.  Revised  by  the  author  from  the  Sixth  and 
enlarged  English  Edition.  Illustrated  by  over  seven  hundred  engravings  on  wood.  In 
two  large  and  beautiful  octavo  volumes  of  over  1700  pages,  cloth,  $9  00  ;  leather,  $11  00. 
{Lately  Issued.) 


Author'' s  Preface  to  the  New  American  Edition. 

“  The  favorable  reception  with  which  the  ‘  Science  and  Art  of  Surgery’  has  been  honored  by  the 
Surgical  Profession  in  the  United  States  of  America  has  been  not  only  a  source  of  deep  gratifica¬ 
tion  and  of  just  pride  to  me,  but  has  laid  the  foundation  of  many  professional  friendships  that 
are  amongst  the  agreeable  and  valued  recollections  of  my  life. 

“I  have  endeavored  to  make  the  present  edition  of  this  work  more  deserving  than  its  predecessors 
of  the  favor  that  has  been  accorded  to  them.  In  consequence  of  delays  that  have  unavoidably 
occurred  in  the  publication  of  the  Sixth  British  Edition,  time  has  been  afforded  to  me  to  add  to  this 
one  several  paragraphs  which  I  trust  will  be  found  to  increase  the  practical  value  of  the  work.” 

Loxdox,  Oct.  1S72. 

On  no  former  edition  of  this  work  has  the  author  bestowed  more  pains  to  render  it  a  complete  and 
satisfactory  exposition  of  British  Surgery  in  its  modern  aspects.  Every  portion  has  been  sedu¬ 
lously  revised,  and  a  large  number  of  new  illustrations  have  been  introduced.  In  addition  to  the 
material  thus  added  to  the  English  edition,  the  author  has  furnished  for  the  American  edition  such 
material  as  has  accumulated  since  the  passage  of  the  sheets  through  the  press  in  London,  so  that 
the  work  as  now  presented  to  the  American  profession,  contains  his  latest  views  and  experience. 

The  increase  in  the  size  of  the  work  has  seemed  to  render  necessary  its  division  into  two  vol¬ 
umes.  Great  care  has  been  exercised  in  its  typographical  execution,  and  it  is  confidently  pre¬ 
sented  as  in  every  respect  worthy  to  maintain  the  high  reputation  which  has  rendered  it  a  stand¬ 
ard  authority  on  this  department  of  medical  science. 

These  are  only  a  few  of  the  points  in  which  the  states  in  his  preface,  they  are  not  confined  to  any  one 
present  edition  of  Mr.  Erichsen’s  work  surpasses  its  portion,  but  are  distributed  generally  through  the 
predecessors.  Throughout  there  is  evidence  of  a  subjects  of  which  the  work  treats.  Certainly  one  of 
laborious  care  and  solicitude  in  seizing  the  passing  the  most  valuable  sections  of  the  book  seems  to  us  to 
knowledge  of  the  day,  which  reflects  the  greatest  be  that  which  treats  of  the  diseases  of  the  arteries 
credit  on  the  author,  and  much  enhances  the  value  and  the  operative  proceedings  which  they  necessitate 
ofhiswork.  We  can  only  admire  the  industry  which  In  few  text-books  is  so  much  carefully  arranged  in- 
has  enabled  Mr.  Erichsen  thus  to  succeed,  amid  the  formation  collected. — London  Med.  Times  and  Gaz., 
distractions  of  active  practice,  in  producing  emphatic-  Oct.  26,  1S72. 

ally  THE  book  of  reference  and  study  for  British  prac-  The  entire  work,  complete,  as  the  great  English 
titioners  of  surgery.  London  Lancet,  Oct.  26,  1872.  treatise  on  Surgery  of  our  own  time,  is,  we  can  assure 

Considerable  changes  have  been  made  in  this  edi-  our  readers,  equally  well  adapted  for  themost  junior 
lion,  and  nearly  a  hundred  new  illustrations  have  student,  and,  as  a  book  of  reference,  for  the  advanced 
been  added.  It  is  difficult  in  a  small  compass  to  point  practitioner  — Dublin  Quarterly  Journal. 
out  the  alterations  and  additions ;  for,  as  the  author 


TiRVITT  (ROBERT),  M.R.C.S.,  ^c. 

■^THE  PRIXCIPLES  AND  PRACTICE  OF  MODERN  SDRGERT. 

A  new  and  revised  American,  from  tbe  eighth  enlarged  and  improved  London  edition.  Illus¬ 
trated  with  four  hundred  and  thirty -two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00 ;  leather,  $5  00. 


All  that  the  surgical  student  or  practitioner  could 
desire. — Dublin  Quarterly  Journal. 

It  is  a  most  admirable  book.  We  do  not  know 
when  we  have  examined  one  with  more  pleasure. — 
Bo.ston  Med.  and  Surg.  Journal. 

In  Mr.  Drnitt’s  book,  though  containing  only  some 
seven  hundred  pages,  both  the  principles  and  the 


practice  of  surgery  are  treated,  and  so  clearly  and 
perspicuously,  as  to  elucidate  every  important  topic. 
We  have  examined  the  book  most  thoroughly,  and 
can  say  that  this  success  is  well  merited.  His  book, 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  and  clas¬ 
sified,  and  of  being  written  in  a  style  at  once  clear 
and  succinct. — Am.  Joicrnalof  Med.  Sciences. 


J^SHTON  {T.  J.). 

OX  THE  DISEASES,  IXJDRIES,  AXD  MALFORMATIOXS  OF 

THE  RECTUM  AND  ANUS;  with  remarks  on  Habitual  Constipation.  Second  American, 
from  the  fourth  and  enlarged  London  edition.  With  handsome  illustrations.  In  one  very 
beautifully  printed  octavo  volume  of  about  300  pages,  cloth,  $3  25. 


TJIGELO  IT  {HENRY  J.),  M.  D., 

Professor  of  Surgery  in  the  Massachvusetts  Med,.  College. 

ox  THE  MECHANISM  OF  DISLOCATION  AND  FRA'CTHRB 

OF  THE  HIP.  With  the  Reduction  of  the  Dislocation  by  the  Flexion  Method.  With 
numerous  original  illustrations.  In  one  very  handsome  octavo  volume.  Cloth,  $2  50. 


T  A  YSON  {GEORGE),  F.  R.  C.  S.,  Engl, 

^  Assistant  Surgeon  to  the  Royal  London  Ophthalmic  Hospital,  Moorflelds,  Sec. 

IXJERIES  OF  THE  EYE,  ORBIT,  AXD  EYELIDS:  their  Imme- 

diate  and  Remote  Effects.  With  about  one  hundred  illustrations.  In  one  very  hand¬ 
some  octavo  volume,  cloth,  $3  50. 

It  is  an  admirable  practical  book  in  the  highest  and  best  sense  of  the  phrase. — London  Medical  Times 
and  Gazette,  May  18, 1867. 


Henry  C.  Lea’s  Publications — {Surgery) 


29 


T>RYANT  {THOMAS),  F.R.C.S., 

Surgeon  to  Guy's  Hospital. 

THE  PRACTICE  OF  SURGERY.  With  over  Five  Hundred  En¬ 
gravings  on  Wood.  In  one  large  and  very  handsome  octavo  volume  of  nearly  1000  pages, 
cloth,  $6  25  j  leather,  raised  bands,  $7  25.  {Lately  Piiblished.) 


Again,  the  author  gives  us  his  own  practice,  his 
own  beliefs,  and  illustrates  by  his  own  cases,  or  those 
treated  in  Guy’s  Hospital.  This  feature  adds  joint 
emphasis,  and  a  solidity  to  his  statements  that  inspire 
cuntideuce.  Oue  feels  himself  almost  by  the  side  of 
the  surgeon,  seeing  his  work  and  hearing  his  living 
words.  The  views,  etc.,  of  other  surgeons  are  con¬ 
sidered  calmly  and  fairly,  but  Mr.  Bryant’s  are 
adopted.  Thus  the  work  is  not  a  compilation  of 
other  writings;  it  is  not  an  encyclopaedia,  but  the 
plain  statements,  on  pi'actical  points,  of  a  man  who 
has  lived  and  breathed  and  had  his  being  in  the 
richest  surgical  experience.  The  whole  profession 
owe  a  debt  of  gratitude  to  Mr.  Bryant,  for  his  work 
in  their  behalf  We  are  confident  that  the  American 
profe'siou  will  give  substantial  testimonial  of  their 
feelings  towards  both  author  and  publisher,  by 
speedily  exhausting  this  edition.  We  cordially  and 
heartily  commend  it  to  our  friends,  and  think  that 
no  live  surgeon  cau  afford  to  be  without  it — Detroit 
Review  of  Med.  and  Pharmacy,  August,  1873. 

As  a  manual  of  the  practice  of  surgery  for  the  use 
of  the  student,  we  do  not  hesitate  to  pronounce  Mr. 
Bryant’s  book  a  first-rate  work.  Mr.  Bryant  has  a 
good  deal  of  the  dogmatic  energy  which  goes  with 
the  clear,  pronounced  opinions  of  a  man  whose  re¬ 
flections  and  experience  have  moulded  a  character 
not  wanting  in  firmness  and  decision.  At  the  same 
time  he  teaches  withVhe  enthusiasm  of  one  who  has 
faith  in  his  teaching, >he  speaks  as  one  having  au¬ 
thority,  and  herein  lies  the  charm  and  excellence  of 
his  work.  He  states  the  opinions  of  others  freely 


and  fairly,  yet  it  is  no  mere  compilation.  The  book 
combines  much  of  the  merit  of  the  manual  with  the 
merit  of  the  monograph.  One  may  recognize  in 
almost  every  chapter  of  the  ninety-four  of  which  the 
work  is  made  up  the  acuteness  of  a  surgeon  who  has 
seen  much,  and  observed  closely,  and  who  gives  forth 
the  results  of  actual  experience.  In  conclusion  we 
repeat  what  we  stated  at  first,  that  Mr.  Bryant’s  book 
is  one  which  we  can  conscientiously  recommend  both 
to  practitioners  and  students  as  an  admirable  work. 
— Dublin  Journ.  of  Med.  Science,  August,  1873. 

Mr.  Bryant  has  long  been  known  to  the  reading 
portion  of  the  profession  as  an  able,  clear,  and  graphic 
writer  upon  surgical  subjects.  The  volume  before 
us  is  one  eminently  upon  the  practice  of  surgery  and 
not  one  which  treats  at  length  on  surgical  pathology, 
though  the  views  that  are  entertained  upon  tnis  sub¬ 
ject  are  sufficiently  interspersed  through  the  work 
for  all  practical  purposes.  As  a  text-book  we  cheer¬ 
fully  recommend  it,  feeling  convinced  that,  from  the 
subject-matter,  and  the  concise  and  true  way  Mr. 
Bryant  deals  with  his  subject,  it  will  prove  a  for¬ 
midable  rival  among  the  numerous  surgical  text¬ 
books  which  are  offered  to  the  student. — N.  Y.  Med. 
Record,  June,  1873. 

This  is,  as  the  preface  states,  an  entirely  new  book, 
and  contains  in  a  moderately  condensed  form  all  the 
surgical  information  necessary  to  a  general  practi¬ 
tioner.  It  is  written  in  a  spirit  consistent  with  the 
present  improved  standard  of  medical  and  surgical 
science. — American  Jotcrnal  of  Obstetrics,  August, 
1873. 


X^ELLS  {J.  SOELBERG), 

X  f  Professor  of  Ophthalmology  in  King's  College  Hospital,  ' &c. 

A  TREATISE  ON  DISEASES  OF  THE  EYE.  Second  AmericaD, 

from  the  Third  and  Revised  London  Edition,  with  additions;  illustrated  with  numerous 
engravings  on  wood,  and  six  colored  plates.  Together  with  selections  from  the  Test-types 
of  Jaeger  and  Snellen.  In  one  large  and  very  handsome  octavo  volume  of  nearly  800 
pages;  cloth,  $5  00;  leather,  $6  00.  {Lately  Published.') 

The  continued  demand  for  this  work,  both  in  England  and  this  country,  is  sufficient  evidence 
that  the  author  has  succeeded  in  his  effort  to  supply  within  a  reasonable  compass  a  full  practical 
digest  of  ophthalmology  in  its  most  modern  aspects,  while  the  call  for  repeated  editions  has  en¬ 
abled  him  in  his  revisions  to  maintain  its  position  abreast  of  the  most  recent  investigations  and 
improvements.  In  again  reprinting  it,  every  effort  has  been  made  to  adapt  it  thoroughly  to  the 
wants  of  the  American  practitioner.  Such  additions  as  seemed  desirable  have  been  introduced 
by  the  editor.  Dr.  I.  Minis  Hays,  and  the  number  of  illustrations  has  been  largely  increased.  The 
importance  of  test-types  as  an  aid  to  diagnosis  is  so  universally  acknowledged  at  the  present  day 
that  it  seemed  essential  to  the  completeness  of  the  work  that  they  should  be  added,  and  as  the 
author  recommends  the  use  of  those  both  of  Jaeger  and  of  Snellen  for  different  purposes,  selec¬ 
tions  have  been  made  from  each,  so  that  the  practitioner  may  have  at  command  all  the  assist¬ 
ance  necessary.  Although  enlarged  by  one  hundred  pages,  it  has  been  retained  at  the  former 
very  moderate  price,  rendering  it  one  of  the  cheapest  volumes  before  the  profession. 

A  few  notices  of  the  previous  edition  are  subjoined. 


Ou  examining  it  carefully,  one  is  not  at  all  sur- 
pri-ed  that  it  should  meet  with  universal  favor.  It 
i.",  in  fact,  a  comprehensive  and  thoroughly  practical 
treatise  ou  diseases  of  the  eye,  setting  forth  the  prac¬ 
tice  of  the  leading  oculists  of  Europe  and  America, 
and  giving  the  author’s  own  opinions  and  preferences, 
which  are  quite  decided  and  worthy  of  high  consid¬ 
eration.  The  third  English  edition,  from  which  this 
is  taken,  having  been  revised  by  the  author,  com¬ 
prises  a  notice  of  all  the  more  recent  advances  made 
in  ophthalmic  science.  The  style  of  the  writer  is 


lucid  and  flowing,  therein  differing  materially  from 
some  of  the  translations  of  C-mtinental  writers  on  this 
subject  that  are  in  the  market.  Special  pains  are 
taken  to  explain,  at  length,  those  subjects  which  are 
particularly  difficult  of  comprehension  to  the  begin¬ 
ner,  as  the  use  of  the  ophthalmoscope,  the- interpre¬ 
tation  of  its  images,  etc.  The  book  is  profusely  and 
ably  illustrated,  and  at  the  end  are  to  be  found  16 
excellent  colored  ophthalmoscopic  figures,  which  are 
copies  of  some  of  the  plates  of  Liebreich’s  admirable 
atlas. — Kansas  City  Med.  Journ.,  June,  187-4. 


TA  VRENCE  {JOHN  Z.),  F.  R.  C.  S., 

Editor  of  the  Ophthalmic  Review,  &c. 


A  HANDY-BOOK  OF  OPHTHALMIC  SURGERY,  for  the  use  of 

Practitioners.  Second  Edition,  revised  and  enlarged.  With  numerous  illustrations.  In 
one  very  handsome  octavo  volume,  cloth,  $3  00. 


For  those,  however,  who  must  assume  the  care  of 
diseases  and  injuries  of  the  eye,  and  who  are  too 
much  pressed  for  time  to  study  the  classic  works  on 
the  subject,  or  those  recently  published  by  Stellwag, 
Wells,  Bader,  and  others,  Mr.  Laurence  will  prove  a 
safe  and  trustworthy  guide.  He  has  described  in  this 


edition  those  novelties  which  have  secured  the  confi¬ 
dence  of  the  profession  since  the  appearance  of  his 
last.  The  volume  has  been  considerably  enlarged 
and  improved  by  the  revision  and  additions  of  its 
author,  expressly  for  the  American  edition. — Am, 
Journ.  Med.  Sciences,  Jan.  1870. 


30 


Henry  C.  Lea’s  Publications-— -(iS^wrgrery,  Sc.). 


rpHOMPSON{SIR  HENRY), 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital. 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.  With 

illustrations  on  wood.  Second  American  from  the  Third  English  Edition.  In  one  neat 
octavo  volume.  Cloth,  $2  25.  {Now  Ready.) 

My  aim  has  been  to  produce  in  the  smallest  possible  compass  an  epitome  of  practical  knowl¬ 
edge  concerning  the  nature  and  treatment  of  the  diseases  which  form  the  subject  of  the  work  ; 
and  I  venture  to  believe  that  my  intention  has  been  more  fully  realized  in  this  volume  than  in 
either  of  its  predecessors. — Author"' s  Preface. 

THE  SAME  AUTHOR.  ^ 

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHRA  AND  URINARY  FISTUL.®.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  cloth,  $3  50. 
{Lately  Published.) 

^Y  THE  SAME  AUTHOR.  {Just  Issued.) 

THE  DISEASES  OF  THE  PROSTATE,  THEIR  PATHOLOGY 

AND  TREATMENT.  Fourth  Edition,  Revised.  In  one  very  handsome  octavo  volume  of 
355  pages,  with  thirteen  plates,  plain  and  colored,  and  illustrations  on  wood.  Cloth,  $3  75. 

rj^AYLOR  [ALFRED  S.),  M.D., 

A  Lecturer  on  Med.  Junsp.  and  Chemistry  in  Guy's  Hospital 

MEDICAL  JURISPRUDENCE.  Seventh  American  Edition.  Edited 

by  John  J.  PtEESE,  M.D.,  Prcf.  of  Med.  Jurisp.  in  the  Univ.  of  Penn.  In  one  large 
octavo  volume  of  nearly  900  pages.  Cloth,  $5  00;  leather,  $6  00.  {Just  Issued.) 

In  preparing  for  the  press  this  seventh  American  edition  of  the  “  Manual  of  Medical  Jurispru¬ 
dence^’  the  editor  has,  through  the  courtesy  of  Dr.  Taylor,  enjoyed  the  very  great  advantage  of 
consulting  the  sheets  of  the  new  edition  of  the  author’s  larger  work,  “  The  Principles  and  Prac¬ 
tice  of  Medical  Jurisprudence,”  which  is  now  ready  for  publication  in  London.  This  has  enabled 
him  to  introduce  the  author’s  latest  views  upon  the  topics  discussed,  which  are  believed  to  bring 
the  work  fully  up  to  the  present  time. 

The  notes  of  the  former  editor.  Dr.  Hartshorne,  as  also  the  numerous  valuable  references  to 
American  practice  and  decisions  by  his  successor,  Mr.  Penrose,  have  been  retained,  with  but  few 
slight  exceptions  ;  they  will  be  found  inclosed  in  brackets,  distinguished  by  the  letters  (H.)  and 
(P.).  The  additions  made  by  the  present  editor,  from  the  material  at  his  command,  amount  to 
about  one  hundred  pages;  and  his  own  notes  are  designated  by  the  letter  (R.). 

Several  subjects,  not  treated  of  in  the  former  edition,  have  been  noticed  in  the  present  one, 
and  the  work,  it  is  hoped,  will  be  found  to  merit  a  continuance  of  the  confidence  which  it  has  so 
long  enjoyed  as  a  standard  authority. 

^Y  THE  SAME  AUTHOR.  {Now  Ready.) 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU¬ 
DENCE.  Second  Edition,  Revised,  with  numerous  Illustrations.  In  two  large  octavo 
volumes,  cloth,  $10  00;  leather,  $12  00. 

This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  its  important  subject.  In  laying  it,  in  its  improved  form,  before  the  Ameri¬ 
can  profession,  the  publisher  trusts  that  it  will  assume  the  same  position  in  this  country. 

THE  SAME  AUTHOR.  New  Edition — Nearly  Ready. 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.  Third  American,  from  the  Third  and  Revised  English  Edition.  In  one 
large  octavo  volume  of  850  pages. 

This  work,  which  has  been  so  long  recognized  as  a  leading  authority  on  its  important  subject, 
has  received  a  very  thorough  revision  at  the  hands  of  the  author,  and  may  be  regarded  as  a 
new  book  rather  than  as  a  mere  revision.  He  has  sought  to  bring  it  on  all  points  to  a  level 
with  the  advanced  science  of  the  day;  many  portions  have  been  rewritten,  much  that  was  of 
minor  importance  has  been  omitted,  and  every  effort  made  to  condense  a  complete  view  of  the 
subject  within  the  limits  of  a  single  volume.  Dr.  Taylor’s  position  as  an  expert  has  brought 
him  into  connection  with  nearly  all  important  cases  in  England  for  many  years.  He  thus  speaks 
with  an  authority  that  few  other  living  men  possess,  while  his  intimate  acquaintance  with  the 
literature  of  toxicology  on  both  sides  of  the  Atlantic,  renders  his  work  equally  adapted  as  a 
text-book  in  this  country  as  in  Great  Britain. 

OOlsrTE]^TTS. 

Poisons. — Absorption  and  Elimination — Detection — Action — Influence  of  Habit — Classifica¬ 
tion  of  Poisons — Evidence  of  Poisoning — Diseases  resembling  Poisoning — Inspection  of  the  Dead 
Body-— Objects  of  Chemical  Analysis — Moral  and  Circumstantial  Evidence  in  Poisoning,  &c.  &c. 

Irritant  Poisons. — Mineral  Irritants — Acid  Poisons — Alkaline  Poisons — Non-Metallic  Irri¬ 
tants — Metallic  Irritants — Vegetable  Irritants — Animal  Irritants. 

Neurotic  Poisons. — Cerebral  or  Narcotic  Poisons — Spinal  Poisons — Cerebro-Spinal  Poisons — 
Cerebro-Cardiac  Poisons. 


Henry  C.  Lea’s  Publications — {Psychological  Medicine^  &c.),  31 


rpUKE  [DANIEL  HACK),  M.D., 

Joint  author  of  “  The  Manual  of  Psychological  Medicine,"  &e. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.  Designed  to  illustrate  the  Action  of  the 
Imagination.  In  one  handsome  octavo  volume  of  416  pages,  cloth,  $3  25.  {Just  Isstied.) 

The  object  of  the  author  in  this  work  has  been  to  show  not  only  the  effect  of  the  mind  in  caus¬ 
ing  and  intensifying  disease,  but  also  its  curative  influence,  and  the  use  which  may  be  made  of 
the  imagination  and  the  emotions  as  therapeutic  agents.  Scattered  facts  bearing  upon  this  sub¬ 
ject  have  long  been  familiar  to  the  profession,  but  no  attempt  has  hitherto  been  made  to  collect 
and  systematize  them  so  as  to  render  them  available  to  the  practitioner,  by  establishing  the  seve¬ 
ral  phenomena  upon  a  scientific  basis.  In  the  endeavor  thus  to  convert  to  the  use  of  legitimate 
medicine  the  means  which  have  been  employed  so  successfully  in  many  systems  of  quackery,  the 
author  has  produced  a  work  of  the  highest  freshness  and  interest  as  well  as  of  permanent  value. 


ULANDFORD  [G.  FIELDING),  M.  D.,  F.  R.  C  F., 

Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  &c. 

INSANITY  AND  ITS  TREATMENT;  Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.  With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane.  By  Isaac  Ray,  M.  D.  In  one  very 
handsome  octavo  volume  of  471  pages;  cloth,  $3  25. 

This  volume  is  presented  to  meet  the  want,  so  frequently  expressed,  of  a  comprehensive  trea¬ 
tise,  in  moderate  compass,  on  the  pathology,  diagnosis,  and  treatment  of  insanity.  To  render  it  of 
more  value  to  the  practitioner  in  this  country.  Dr.  Ray  has  added  an  appendix  which  affords  in¬ 
formation,  not  elsewhere  to  be  found  in  so  accessible  a  form,  to  physicians  who  may  at  any  moment 
be  called  upon  to  take  action  in  relation  to  patients. 


It  satisfies  a  want  which  must  have  been  sorely 
felt  by  the  busy  general  practitioners  of  this  country. 
It  takes  the  form  of  a  manual  of  clinical  description 
of  the  various  forms  of  insanity,  with  a  description 
of  the  mode  of  examining  persons  suspected  of  in¬ 
sanity.  We  call  particular  attention  to  this  feature 
of  the  book,  as  giving  it  a  unique  value  to  the  gene¬ 
ral  practitioner.  If  we  pass  from  theoretical  conside¬ 
rations  to  de.scriptions  of  the  varieties  of  insanity  as 


actually  seen  in  practice  and  the  appropriate  treat¬ 
ment  for  them,  we  find  in  Dr.  Blandford’s  work  a 
considerable  advance  over  previous  writings  on  the 
subject.  His  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  reader  can  fail 
to  be  struck  with  their  superiority  to  those  given  in 
irdiuary  manuals  in  the  English  language*  or  (so  far 
as  our  own  reading  extends;  in  any  other. — London 
Practitioner ,  Eeb.  1871. 


LYIKSLOW  [FORBES),  M.D.,  D.C.L.,^c. 

^  ON  OBSCURE  DISEASES  OF  THE  BRAIN  AND  DISORDERS 

OF  THE  MIND;  their  incipient  Symptoms,  Pathology,  Diagnosis,  Treatment,  and  Pro¬ 
phylaxis.  Second  American,  from  the  third  and  revised  English  edition.  In  one  handsome 
octavo  volume  of  nearly  600  pages,  cloth,  $4  25. 


T  EA  [HENRY  C.). 

^SUPERSTITION  AND  FORCE:  ESSAYS  ON  THE  WAGER  OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.  Second  Edition, 
Enlarged.  In  one  handsome  volume  royal  12mo.  of  nearly  500  pages;  cloth,  $2  75. 


{haiely  P^iblisJted.) 

We  know  of  no  single  work  which  contains,  in  so 
amall  a  compass,  so  much  illustrative  of  the  strange.**! 
operations  of  the  human  mind.  Foot-notes  give  the 
authority  for  each  statement,  showing  vast  research 
and  wonderful  industry.  We  advise  our  confreres 
to  read  this  book  and  ponder  its  teachings. — Chicago 
Med.  Journal,  Aug.  1870. 

As  a  work  of  curious  inquiry  on  certain  outlying 
points  of  obsolete  law,  “Superstition  and  Force’’  is 
one  of  the  most  remarkable  books  we  have  met  with. 
—London  AthencBum,  Nov.  8,  1866. 

He  has  thrown  a  great  deal  of  light  upon  what  must 
be  regarded  as  one  of  the  most  instructive  as  well  as 


interesting  phases  of  human  society  and  progress.  . 
The  fulness  and  breadth  wi^h  which  he  has  carried 
out  his  comparative  survey  of  this  repulsive  field  of 
history  [Torture],  are  such  as  to  preclude  our  doing 
justice  to  the  work  within  our  present  limits.  But 
here,  as  throughout  the  volume,  there  will  be  found 
a  wealth  of  illustration  and  a  critical  grasp  of  the 
philosophical  import  of  facts  which  will  render  Mi. 
Lea’s  labors  of  sterling  value  to  the  historical  stu¬ 
dent. — London  Saturday  Review,  Oct.  8,  1870. 

As  a  book  of  ready  reference  on  the  subject,  it  is  of 
the  highest  value. —  Westminster  Review,  Oct.  1867. 


I>r  THE  SAME  AUTHOR.  {Lately  Published.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF  THE  TEM¬ 
PORAL  POWER— BBNBFII  OF  CLERGY— EXOOMMDNICATION.  In  one  large  royal 
12mo.  volume  of  516  pp.  cloth,  $2  75. 


The  story  was  never  told  more  calmly  or  with 
greater  learning  or  wiser  thought.  We  doubt,  indeed. 
If  any  other  study  of  this  field  can  be  compared  with 
this  for  clearness,  accuracy,  and  power.  —  Chicago 
Examiner,  Dec.  1870. 

Mr.  Lea’s  latest  work,  “Studies  in  Church  History,” 
fully  sustains  the  promise  of  the  first.  It  deals  with 
three  subjects — the  Temporal  Power,  Benefit  of 
Clergy,  and  Excommunication,  the  record  of  which 
has  a  peculiar  importance  for  the  English  student,  and 
is  a  chapter  on  Ancient  Law  likely  to  be  regarded  as 
final.  We  can  hardly  pass  from  our  mention  of  such 
works  as  these — with  which  that  on  “Sacerdotal 
Celibacy”  should  be  included — without  noting  the 


literary  phenomenon  that  the  head  of  one  of  the  first 
American  houses  is  also  the  writer  of  some  of  its  most 
original  books. — London  Athenceum,  Jan.  7,  1871. 

Mr.  Lea  has  done  great  honor  to  himself  and  this 
country  by  the  admirable  works  he  has  written  on 
ecclesiologicaland  cognate  subjects.  We  have  already 
had  occasion  to  commend  his  “Superstition  and 
Force”  and  his  “History  of  Sacerdotal  Celibacy.” 
The  present  volume  is  fully  as  admirable  in  its  me¬ 
thod  of  dealing  with  topics  and  in  the  thoroughness — 
a  quality  so  frequently  lacking  in  American  authors— 
with  which  they  are  investigated. — N.  Y.  Journal  of 
Psychol.  Medicine,  July,  1870. 


82 


Henry  C.  Lea's  Publications 


INDEX  TO  CATALOGDE. 


Ambricau  Journal  of  the  Medical  Sciences 
Abstract,  Half-Yearly,  of  the  Med.  Sciences 
Anatomical  Atlas,  by  Smith  and  Horner 
Anderson  on  Diseases  of  the  Skin 
Ashton  on  the  Rectum  and  Anus 
Attfield’s  Chemistry 
Ashwell  on  Diseases  of  Females 
Ashhurst’s  Surgery 
Barnes  on  Diseases  of  Women 
Bellamy’s  Surgical  Anatomy 
Bryant’s  Practical  Surgery 
Bloxam’s  Chemistry 
Blandford  on  Insanity  . 

Basham  on  Renal  Diseases 
Brinton  on  the  Stomach 
Bigelow  on  the  Hip 
Barlow’s  Practice  of  Medicine 
Bowman’s  (John  E.)  Practical  Chemistry 
Bowman’s  (John  E.)  Medical  Chemistry 
Bnmstead  on  Venereal  .... 

.  Bumstead  and  Cullerier’s  Atlas  of  Venerea 
Carpenter’s  Human  Physiology  . 
Carpenter’s  Comparative  Physiology  . 
Carpenter  on  the  Use  and  Abuse  of  Alcohol 
Carson’s  Synopsis  of  Materia  Medica  . 
Chambers  on  Diet  and  Regimen  . 

Chambers’s  Restorative  Medicine 
Christison  and  Griffith’s  Dispensatory 
Churchill’s  System  of  Midwifery  . 

Churchill  on  Puerperal  Fever 
Condie  on  Diseases  of  Children  . 

Cooper’s  (B.  B.)  Lectures  on  Surgery  . 
Cullerier’s  Atlas  of  Venereal  Diseases 
Cyclopedia  of  Practical  Medicine  . 

Dalton’s  Human  Physiology  . 

Davis’  Clinical  Lectures 
De  Jongh  on  Cod-Liver  Oil  . 

Dewees  on  Diseases  of  Females  .  . 

Dewees  on  Diseases  of  Children  . 

Druitt’s  Modern  Surgery 
Dunglison’s  Medical  Dictionary  . 
Dunglison’s  Human  Physiology  . 

Dunglison  on  New  Remedies 
Etlis’s  Medical  Formulary,  by  Smith  . 
Erichsen’s  System  of  Surgery 
Fenwick’s  Diagnosis  .... 

Flint  on  Respiratory  Organs  . 

Flint  on  the  Heart . 

Flint’s  Practice  of  Medicine  . 

Flint’s  Essays  _ . 

Flint  on  Phthi.sis  .  .  .  -  . 

Fownes’s  Elementary  Chemistry  . 

Fox  on  Diseases  of  the  Stomach  . 

Fulleron  the  Lungs,  &c. 

Green’s  Pathology  and  Morbid  Anatomy 

Gibson’s  Surgery  . 

Gluge’s  Pathological  Histology,  by  Leidy 
Galloway’s  Qualitative  Analysis  , 

Gray’s  Anatomy . 

Griffith’s  (R.  E.)  Universal  Formulary 
Gross  on  Foreign  Bodies  in  Air-Passages 
Gross’s  Principles  and  Practice  of  Surgery 
Guersant  on  Surgical  Diseases  of  Children 
Hamilton  on  Dislocations  and  Fractures 
Hartshorne’s  Essentials  of  Medicine  . 
Hartshorne’s  Conspectus  of  the  Medical  Scie 
Hartshorne’s  Anatomy  and  Physiology 
Heath’s  Practical  Anatomy  . 

Hoblyn’s  Medical  Dictionary 

Hodge  on  Women . 

Hodge’s  Obstetrics . 

Hodges’  Practical  Dissections 
Holland’s  Medical  Notes  and  Reflections 
Horner’s  Anatomy  and  Histology 
Hudson  on  Fevers  .... 

Hill  on  Venereal  Diseases 
Hillier’s  Handbook  of  Skin  Diseases 
Jones  and  Sieveking’s  Pathological  Anatomy 
Jones  (C.  Handfleld)  on  Nervous  Disorders 


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PA 


Kirkes’  Physiology 
Knapp’s  Chemical  Technology 
Lea’s  Superstition  and  Force 
Lea's  Studies  in  Church  History 
Lee  on  Syphilis 

Lincoln  on  Electro-Therapeutics 
Leishman’s  Midwifery  . 

La  Roche  on  Yellow  Fever  . 

La  Roche  on  Pneumonia,  &c. 

Laurence  and  Moon’s  Ophthalmic  Surgery 
Lawson  on  the  Eye 
Laycock  on  Medical  Observation 
Lehmann’s  Physiological  Chemistry,  2  vols 
Lehmann’s  Chemical  Physiology  . 

Ludlow’s  Manual  of  Examinations 
Lyons  on  Fever  .... 

Maclise’s  Surgical  Anatomy  . 

Marshall’s  Physiology  . 

Medical  News  and  Library  . 

Meigs’s  Lectures  on  Diseases  of  Women 
Meigs  on  Puerperal  Fever 
Miller’s  Practice  of  Surgery  . 

Miller’s  Principles  of  Surgery 
Montgomery  on  Pregnancy  . 

Neill  and  Smith’s  Compendium  of  Med.  Science 
Neligan’s  Atlas  of  Diseases  of  the  Skin 
Neligan  on  Diseases  of  the  Skin 
Obstetrical  Journal 
Odling’s  Practical  Chemistry 
Pavy  on  Digestion 
Pavy  on  Food  .... 

Parrish’s  Practical  Pharmacy 
Pirrie’s  System  of  Surgery  . 

Pereira’s  Mat.  Medica  and  Therapeutics,  abridged 
Quain  and  Sharpey’s  Anatomy,  by  Leidy 
Roberts  on  Urinary  Diseases  . 

Ramsbotham  on  Parturition  . 

Rigby’s  Midwifery . 

Royle’s  Materia  Medica  and  Therapeutics 
Swayne’s  Obstetric  Aphorisms 
Sargent’s  Minor  Surgery 
Sharpey  and  Quain’s  Anatomy,  by  Leidy 
Skey’s  Operative  Surgery 
Slade  on  Diphtheria  .... 

Smith  (J.  L.)  on  Children  .  .  . 

Smith  (H.  H.)  and  Horner’s  Anatomical  Atla 
Smith  (Edward)  on  Consumption  . 

Smith  on  Wasting  Diseases  *.  Children 
Still6’s  Therapeutics  .... 

Sturges  on  Clinical  Medicine 

Stokes  on  Fever . 

Tanner’s  Manual  of  Clinical  Medicine  . 

Tanner  on  Pregnancy  . 

Taylor’s  Medical  Jurisprudence  . 

Taylor’s  Principles  and  Practice  of  Med  Jurisp 
Taylor  on  Poisons  .... 

Tuke  on  the  Influence  of  the  Mind, 

Thomas  on  Diseases  of  Females  ! 

Thompson  on  Urinary  Organs 
Thompson  on  Stricture  . 

Thompson  on  the  Prostate 
Todd  on  Acute  Diseases  . 

Walshe  on  the  Heart 
Watson’s  Practice  of  Physic 
Wells  on  the  Eye  . 

West  on  Diseases  of  Females 
Weston  Diseases  of  Children 
West  on  Nervous  Disorders  of  Children 
What  to  Observe  in  Medical  Cases 
Williams  on  Consumption  . 

Wilson  s  Human  Anatomy  . 

Wilson  on  Diseases  of  the  Skin  . 

Wilson’s  Plates  on  Diseases  of  the  Skin 
Wilson’s  Handbook  of  Cutaneous  Medicine 
Winslow  on  Brain  and  Mind 
Wohler’s  Organic  Chemistry 
Winckel  on  Childbed 
Zeissl  on  Venereal  . 


19 


For  “The  Obstetrical  Journal,”  Five  Dollars  a  year,  see  p.  22. 


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